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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. Factual statements may or may not be true. I may change ages, gender or presenting complaints about patients. I may even entirely make up complete patient encounters from my fertile imagination. Trust me, if you think I’m writing about you, I’m not. There are billions of people in this world and readers send me stories about patients all the time. It isn’t you.
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 — 12-10-2010

Did I tell you how much Google sucks … BLAM! Droid phone explodes in man’s head while he is talking on phone. Emergency department overcrowding takes another life. Short of breath 41 year old Ontario patient dies while sitting in emergency department waiting room for more than 90 minutes. Waits for patients with serious conditions can reach more than 12 hours. Some admitted patients waited more than 26 hours for a hospital bed to open up. Downright scary emails from Alberta, Canada emergency physician to top Canadian political and health care leaders documenting lack of care in emergency departments. Direct link for .pdf download is here. Waits of 5.5 hours for a potential stroke victim to get a bed. No tPA for you! Another potential stroke patient leaves after five hours without seeing a physician. A nine hour wait for a patient experiencing seizures. A man dies because he needed emergency brain surgery and couldn’t get it because of “overwhelming systemic overcrowding”. A suicidal patient leaves without seeing a doctor and then returns by ambulance after overdosing on prescription medications. Another patient boarded in the emergency department for an entire week. Patients in the waiting room threatening triage nurses and “screaming that we are letting people die.” Did I mention that all those patients had national health “insurance”? Oh just cut the damn payments already. Congress staves off physician Medicare payment cuts … again. Because we’re suddenly going to find hundreds of billions of dollars to make the system solvent in the next 12 months. Next time that we have to read about the same brinksmanship and watch Congress kick the can down the road a few more months: January 2012. There’s the French Kiss, then there’s the … Sheboygan Chomp. Sheboygan, Wisconsin man ends up in emergency department after wife bites off half his tongue during kiss. The 79 year old victim noted that his 59 year old wife had been “acting strangely” for several days. No argument there. “911 … please hold.” Louisiana appellate court throws out limit on malpractice awards, stating that the law is discriminatory because lesser-injured patients receive a full payout for damages, while more severely injured patients have their damage awards limited. In this case, a child was awarded $6.2 million, but her award was decreased to the statutory maximum of $500,000. If you were a physician, would this ruling have any effect on your willingness to practice medicine in Louisiana? Georgia hospitals considers “program changes” to deal with unpaid medical care. Charity care at the Medical Center of Central Georgia increased by about $30 million in the latest year reported while uncompensated care statewide was estimated at $1.3 billion. I’ve got a better idea. Let’s just create more regulations. Meanwhile, despite lower patient volumes in 70% of hospitals across the country, according to an American Hospital Association analysis, US community hospitals provided a total of $75 billion in unpaid care in 2009 – a significant increase from prior years. A different AHA survey released the same day showed that hospitals were able to earn a 5% profit margin in 2009. “English only” or just “No Filipinos allowed”? California hospital establishes an “English only” policy for all of its workers, but then allegedly selectively enforces the policy against Filipinos while allowing Hispanic and Indian nurses to speak their native languages on the job. Now the EEOC has filed a lawsuit over the issue. Nurses have more back injuries than truck drivers and more than half of nurses have experienced violence on the job. The article describes how nurses in California have been murdered by ...

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Inevitable Malpractice

I’ll preface this post by saying that, as I usually do when discussing specific patient presentations, I made multiple factual changes in the factual information regarding the patient. An 87 year old lady who is in excellent health comes into the department because she couldn’t move her leg. When she woke up and was fine. Her family helped her get dressed. She read the newspaper at breakfast. Then she went to the bathroom, was in there about 15 minutes, and began yelling for help because her leg hurt and she couldn’t get off the toilet. The family thought that she was sitting too long on the toilet, irritating her sciatic nerve, and thought she just needed to let her leg relax for a little while. A couple of hours later, her leg was hurting her more and she still couldn’t move it, so they called the ambulance. This was a wonderful little lady who looked like she was 60. She was well-dressed. She carried on a normal conversation and was completely coherent. She joked back and forth with us. Her hair was done up perfectly and she had a fresh manicure. She took a blood pressure pill each day and that was about it. Unfortunately, when you looked at her leg, it was mottled and cold from the mid-thigh to her toes. It was obvious that she had an acute arterial occlusion of her leg. See an example on the right side of the picture above where there is no dye advancing in the femoral artery past the mid-thigh. I called our vascular surgeon who came immediately and evaluated the patient. He recommended that she be transferred to the tertiary care center in our area where they had “more experience” dealing with these issues and could perhaps do intra-arterial thrombolytics. I called the vascular surgeon at the tertiary care center and he gave a lot of push back. Why were we transferring the patient when we had a vascular surgeon on staff? He demanded to talk to the patient and the family on the phone. While he was talking to the family, the patient had an episode of pulseless ventricular tachycardia. . The patient was a DNR, so we abided by her wishes and did not resuscitate her. About 30 seconds later, she had a pause in her rhythm and spontaneously converted back to normal sinus rhythm. She woke up asking “what happened?” Upon hearing that the patient had an episode of ventricular tachycardia, the vascular surgeon at the tertiary care center told the family that he would not accept an unstable patient and hung up the phone. The ambulance company refused the transfer. Our vascular surgeon was faced with a Morton’s Fork. If the patient didn’t have surgery, she would lose her leg and would likely die from the ensuing complications. However, the patient was also a high risk for having surgery. She just demonstrated an unstable cardiac rhythm and her cardiac enzymes were abnormal. Surgery would likely kill her. The patient and family both wanted the surgery done. “Life wouldn’t be worth living without her leg,” they said. The anesthesiologist at the hospital was having a cow. “Let me get this straight. You want me to justify providing general anesthesia to a patient with an active heart attack so she can have a major surgery?” Time was running short. The artery must be opened within 6 hours of the event. We were at about 5 hours and 15 minutes from the estimated onset of symptoms. So the patient was taken to surgery to try to re-establish blood flow ...

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Death Panels and Access to Care

I read an article in the New York Times that underscores my argument that health care insurance does not and never will equal health care access. Our federal and state governments are being crushed by debt. There are many reasons for that debt, and addressing the reasons for the debt are a necessary aspect of decreasing the debt. For example, if a family household had overdrawn its checking account by several thousand dollars and their credit cards were maxed out, most people would consider it foolish for the family to purchase expensive cars, to donate large sums of money to charity, to go out to eat at expensive restaurants, or to continue purchasing large amounts of weapons to stockpile in its basement. When in debt, there are two options – earn more money or reduce spending. Using the example of the family in debt, perhaps they sell their assets and move into a smaller house. Perhaps they eat macaroni and cheese for dinner. You get the picture. But if we assume that the family has cut all of its non-essential spending (and many would argue that this part of the analogy fails when applied to state and federal governments), yet is still in debt, then how can the family further reign in costs? That is the problem with which most governmental entities are now faced. Arizona has taken a drastic step to reduce costs. It is now refusing to pay for expensive medical care to some Medicaid patients in need of organ transplants. According to the article, the decision amounts to “Death by budget cut.” Patients such as a father of six (pictured at the right), a plumber, and a basketball coach all need various types of transplants, but are no longer eligible to receive them. The state estimates it will save $4.5 million per year by not providing these services to roughly 100 Arizona citizens. The state also warns that “there will have to be more difficult cuts looking forward.” Read that as Arizona being poised to cut funding for other types of expensive care. Going back to the analogy about the family – is it morally appropriate to just let family members die because you don’t want to pay for the cost of caring for them? This fairy tale about providing “insurance for all” is the biggest problem with the health care overhaul. We can strive to provide “insurance” for everyone, but “insurance” is only as good as what it insures you for. If you are on Medicare and need expensive care or if you live in Arizona and need a transplant, you still have insurance, but that insurance just doesn’t pay for your medical care. Even though patients pay into the system all of their lives, they get nothing out of it when they actually need the care. Ponzi medicine? If governments were serious about providing medical care for patients, they would create a system similar to the VA Hospital system that is available to every citizen in this country. You walk in the door, you get medical care. Perhaps the care wouldn’t be as good or as fast as care available at private facilities, but care would at least be available. As the implementation of health care reform takes place, it begins to appear that our new health care system may provide the most benefits to the people that use it the least. Don’t get sick and you’ll be just fine.

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Healthcare Update — 12-02-2010

Also see the satellite edition of this week’s update over at ER Stories. Problems with Canadian health systems getting worse. “We’re trying to get a Size 13 foot into a Size 8 shoe.” Emergency department overcrowding increasing due to lack of available beds. The president of the Edmonton Emergency Physicians Association described the situation as a “potential catastrophic collapse” of emergency medicine. Edmonton plans to decrease hospital emergency department crowding by moving patients out of the emergency departments sooner once the hospitals meet certain criteria such as the ED being 110% full or there are more than 35% boarding patients in the emergency department. Five times this past year, Dr. Raj Sherman’s 73-year-old father almost died after waiting hours on a stretcher in an ambulance parked outside the hospital waiting for a bed. As a parliamentary assistant on health, he decided he had had enough and blasted the government, the Alberta Health Services chairman, the former health minister, and Premier Ed Stelmach. As a result of his statements, he has been fired from his government position. California emergency physicians sue to keep the state from cutting reimbursement – and win. Medicaid insurance versus Medicaid access. Yes, they have insurance, but one patient had to drive 2.5 hours to see an orthopedist that would accept her insurance. He fitted her with a brace and sent the patient for physical therapy. Now the “insurance” won’t pay for the brace. Plans that are running Medicaid managed care plans are viewed as “managing costs, not managing the care.” When patients can’t get the care they need, where will they end up? Emergency department waiting rooms. Six California hospitals fined because employees inappropriately accessed patients’ medical information. How do we change the system to prevent this from reoccurring? Malpractice judgments and settlements in the news: $16.2 million Chicago settlement for neurosurgical injury after patient sustains a brainstem herniation. $6 million Wisconsin settlement in birth injury case where patient born with cerebral palsy. Largest verdict in Belize history for child who was delivered 2 weeks early due to miscalculation in gestational age and premature Caesarian section. Maine preparing to repeal its universal health care plan due to funding issues. The Governor elect states that the state has paid $160 million to cover 3,400 eligible residents. The outgoing governor disagrees with the numbers. Girlvet has another intriguing post about those warning labels on cigarettes. If cigarette packs are required to have graphic pictures on them, why aren’t beer cans required to have graphic pictures of DWI accidents? Why doesn’t McDonalds have to put graphic pictures of obese people on their bags? A real life “Catch Me If You Can.” Fake doctor works in Fayetteville, NC emergency department for 3 weeks before getting caught. SWAT team descends on hospital as Florida gunman fires shots in hospital cafeteria and then barricades himself inside hospital room. Canadian man has diabetic “seizure” while visiting his wife and newborn daughter. Instead of bringing him to the emergency department, the hospital calls an ambulance and paramedics bring the man to the emergency department where he is later released. Now there’s the little matter of that $400 ambulance fee that he’s being charged – even though he never set foot in an ambulance. One reason that some medical providers are reluctant to disclose errors: 25% of patients stated that they would file a medical malpractice lawsuit if they were told about a medical error. Many actions considered “medical errors” have no effect on patient outcomes. Giving a medication five minutes after the time it was ordered is a medical “error”. Giving ice chips to ...

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New Defensive Medicine Survey

“Every word that I write on every form is crafted with the idea that a malpractice attorney will challenge me to defend my practice.” Just one of the quotes in the survey about defensive medicine published by Jackson Healthcare. The survey of more than 3000 physicians showed that 92% admitted practicing defensive medicine and that, based on physician responses, the annual estimated cost of defensive medicine in the US each year is $650 billion to $850 billion – accounting for $1 out of every $4 spent on US health care. You probably shouldn’t believe any of the statistics or quotes from physicians in the survey, though. Trial lawyers have a much better idea about why physicians order so many tests and why defensive medicine has no impact on the availability of health care in our system.

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Healthcare Update — 11-19-2010

Malpractice environment in Texas improves, doctors flock to state. In the three years after tort reform took place in Texas, 7000 doctors applied for Texas medical licenses. Malpractice environment in Illinois stays bad, doctors leave. According to a recent Northwestern University study (.pdf file, see story here), 70% of medical students who planned to leave Illinois after graduation cited Illinois’ “anti-doctor liability environment” as playing a role in their decision. The study predicts that rural communities in Illinois will remain underserved due to lack of physicians. So which is more important, perfect care or available care? St. Joseph Hospital in Baltimore pays $22 million to settle claims that it was performing unnecessary cardiac stenting procedures in patients. Three cardiologists who blew the whistle on the hospital get a cut of the settlement. That leaves the hospital with only 101 more lawsuits to defend due to the allegations. Can computers help curb “unnecessary tests”? According to the Institute for Clinical Systems Improvement, a computer program has reportedly saved Minnesota $28 million per year by “eliminating thousands of unnecessary tests.” The project in Minnesota discovered that physicians chose clinically unuseful testing approximately 10% of the time, so insurers agreed to forgo prior authorizations for testing if doctors used the program. Two problems with the system and the article mentions them: Defensive medicine and patient satisfaction. If doctors perceive that they are going to reduce liability by ordering the test, they’re going to order the test, and if doctors are getting graded by how happy they make patients, when patients want the test, doctors are going to order the test. Despite the shortcomings, the program has been so successful that the federal government is considering whether or not to implement it on a national basis. New York woman wins $3.5 million in a jury trial after requiring lower leg amputation due to “emergency room delays” in treating a knee dislocation. Team Health, one of several national emergency department staffing companies, had third-quarter profit that was up 30% due to recent acquisitions and improved contract volume. University of Minnesota’s medical malpractice cases going down, but costs remain stable. The University spent $4.3 million to defend 42 claims filed against the University since 2005. It spent almost $740,000 to get 16 cases dismissed before trial and spent another $2.5 million settling and defending 15 other cases. Four cases went to trial and the University won all of them. The numbers in the article don’t add up, but do give at least an idea of what it costs to defend malpractice cases. Good way for insurers to make lots of money: Collect premiums, insure patients, don’t pay (or underpay) claims for a few years, then go bankrupt. California insurer La Vida did just that, sticking many emergency medical providers with years of unpaid bills. Some people go to the emergency department and get treatment for bedbug bites … some people go to the emergency department and get bedbug bites. Bedbug infestation found in two rooms at a Milwaukee emergency department. Ewwwwww. How many people started itching after reading this? I can only imagine what the Medical Marijuana Advocates are going say about that one. Interesting factoid from across the pond. In Great Britain, 23% of all cancer cases, including up to 50% of leukemia and brain tumor patients, are initially diagnosed in the emergency department. New Yorkers have drinking problems? Emergency department visits for alcohol-related issues in New York increase 250% from 2003 to 2009. Identity theft ring hits Florida emergency departments. Employee accessed more than 1,500 files and printed patient information which was later sold to other ...

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