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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.

Focus On The Cost

Yeah, I agree with Howard Fineman. You got a problem with that? Read his Newsweek article about his experiences being admitted to an Argentinian hospital and how he believes we should be focused on the costs of health care in this country. His bill for a hospital stay with dehydration in Argentina: About $1500. Similar hospitalization in the US: $10,000 to $15,000 – if he was lucky. Money quote: “Most Americans have no idea how much their health care really costs, nor do they know how well it really works ….” We desperately need price transparency in our health care system. Look at the four systems in Pennsylvania that I reviewed in a previous post. If one hospital cost 4 times as much as another hospital for treating the same medical problem, would that affect anyone’s decision on where to go for medical care? One commenter to the article noted that “Health services are often urgently needed and the consumer doesn’t have the time or inclination to shop around.” If people shop around for weeks to find the best deal on a car and spend all Sunday morning going through newspaper ads to find the cheapest head of broccoli at the grocery store, I have no sympathy for those who “don’t have the time or inclination” to research where they would want to go if their life was on the line or if they needed specialized surgery. Regardless of what health care reform measures are taken, we still need to be educated consumers with our most important assets – our lives.

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I may end up eating my words about this. We’ll see. James Rohack, the current AMA President, made a post at Kevin MD about why patients should care about fixing the pending Medicare payment cuts. Basically his take on the matter was that if the cuts go through, many physicians will stop seeing Medicare patients and that some seniors on Medicare will have difficulty finding medical care. I tend to agree with him. I commented that we should let Congress cut Medicare payments. Stop fighting it. I won’t rehash everything, but suffice it to say that I think we need a crisis in medicine to get things straightened out right now. A Medicare pay cut of 21.2% has been looming over physicians’ heads for several months now. The same pay cut has come up in the past, but, through some last minute “miracle” (otherwise known as brinksmanship), the pay cuts are averted, the deadlines are extended, and the medial societies pat themselves on the back for all of their hard work in averting disaster. Now the stakes just went up. The Senate blocked the latest legislation to extend the deadlines for the pay cut. Pay cuts will take effect on Monday. Physicians now will have to make an important decision. March 17 is the deadline for physicians to decide whether they will continue to participate in the Medicare program. Things are a little more complicated than this, but the basic consequences of the decision are the following: If physicians decide to participate, then they’re stuck with the 21% pay cut. If physicians decide not to participate, then Medicare patients have to pay the physicians’ fees out of pocket — or find another doctor who accepts Medicare. Why don’t all physicians just drop Medicare and then sign back up when the rate cuts go away? Another arcane rule crafted by Medicare – once you decide not to participate, you can’t participate again for a minimum of two years. So do physicians drop low payments and gamble that payments won’t go up in the future? Or do they bite the bullet and continue providing services at even more of a pittance? Our physician organizations need to collectively tell Medicare to go pound sand. Maybe this is what the government wants. Notice how the payroll deductions for Medicare and Medicaid aren’t getting any smaller. But with less people working, the amount of money collected is becoming less and less while the numbers of people needing the services continues to increase. By significantly reducing the number of available providers, perhaps the government wonks believe that they can reduce the amount of money they spend on care. Initially, that may be true. Then what happens? First, a good percentage of about 40 million AARP members, and a significant portion of the rest of the Medicare population, are going to become extremely upset when they can’t find a doctor to take care of them. Then, just based on sheer percentages, every single member of Congress is going to get at least a few phone calls from angry constituents who are no longer able to find medical care. The legislators will go into damage control mode, but it will be too late – because even if Congress raises the pay a week after the opt-out decision deadline, those doctors that opted out still won’t be able to participate in Medicare for another two years. There will be a lot of turnover in Congress in November and that’s something else we need. If a lot of physicians opt out of Medicare, the health care system will turn chaotic. ...

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Healthcare Update – 02-25-2010

Also see the Satellite Edition of this week’s Healthcare Update over at ER Stories. Seven secrets of the ER … including quotes from GruntDoc. Among them, fretch if you want to get to a room more quickly and never lie to your ER nurse. Secret #1 in my hospital: Stop calling it the “ER” already. It’s the emergency department. Want to know why it’s called the emergency department? Here’s an explanation from About.com. Defensive medicine accounts for $650 billion of the $2.5 trillion spent on healthcare annually – or about 25% of all health care dollars. Press release here. I know, I know. Propaganda. Even so, that number is just a little bit more than the figures that the AAJ is throwing around. Study shows that repeal of malpractice caps in Illinois will increase liability claim costs by 18%. I know. More propaganda. Treat me or I’ll BLAST ya’. Nurse and former hospital employee uses guns to get quicker care for a kidney stone, then gets a long-term admit to the Greybar Motel. If this guy got brought back acting all Yosemite Sam with me, I’d be like this: “Yeah, we’re going to give you this IV pain medication that’s great for kidney stones. It’s called succinylcholine. Then, since the department is crowded today, we’re going to have you share a room with this other patient. By the way, you’re not wearing a G-string, are you?” Medical malpractice caps are unconstitutional, huh? Fine, then we’ll change the constitution. After Illinois Supreme Court throws out malpractice reform due to concerns with constitutionality, Illinois State Senator Dave Luechtefeld introduces constitutional amendment that would allow legislation limiting non-economic damages. Child dies when EMTs are dispatched to Avenue C in Brooklyn but the emergency was on Avenue C in Manhattan. Canadian Premier leaves Canada to have minimally invasive heart surgery done in Florida, then writes a check to cover the cost.  I like the free market principles at work here, but what does this decision say about Canadian health care? Canadian docs aren’t very happy. Hat tip to 911Doc. Coming soon to a ballpark near you – warning labels on hot dogs. According to the American Academy of Pediatrics, hot dogs are allegedly “too flexible” and are a choking hazard to children, necessitating a change in design. Worse yet, hot dogs could shoot your eye out (hat tip to Overlawyered) Enter … the dogburger. In other news, due to this report, JCAHO has now mandated that all patients eat only pureed food as a patient safety measure. Oh … and all children will have to get gastrostomy tubes placed so that they won’t choke when trying to swallow food. I feel a rant coming on … Alaskan psychiatrists being sued for prescribing unnecessary psychiatric drugs to children. Six family members hospitalized, five in the ICU, after eating homemade beef stew. I’m no Emeril Lagasse, but when making a stew, pulling weeds out of the backyard and putting them in the pot probably isn’t the best idea … especially when one of the weeds isn’t “mint” but is instead hallucinogenic jimsonweed. Hat tip to LA Times Booster Shots.

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Reducing Bloodstream Infections

There’s this light on my way to work that is just a royal pain. It’s set up so that you have to wait for the arrow to make a left hand turn. The intersection is busy, especially in the mornings, and the arrow only stays lit for about 13 seconds. So you end up waiting five minutes or more – through several light cycles – to make the turn. OR … you can go straight through the intersection, turn left into McDonald’s parking lot, pull out of the parking lot, come back to the intersection from the other direction, and make a right turn, saving yourself 4 minutes and 30 seconds. Now mind you that drivers who choose the latter route are, in effect, going through a red turn arrow – they’re just taking a bunch of extra steps to make sure that they are complying with all of the traffic laws in the process. You’re probably wondering what a traffic light has to do with bloodstream infections. I’ll get to that later. This month, Consumer Reports published a well-written article about reducing hospital infections, and a lot of the take-home messages are good ones. The Consumer Reports article focuses on blood stream infections – also known as “septicemia“. Consumer Reports compared central line infection data for intensive care units at 926 hospitals in 43 states. Hospitals voluntarily submit such information to the Leapfrog Group, a nonprofit organization based in Washington, D.C. and Consumer Reports obtained the data from Leapfrog. As many people realize, septicemia and sepsis can lead to significant mortality in patients. Approximately 20–35% of patients with severe sepsis and 40–60% of patients with septic shock die within 30 days. Anything that we can do to prevent bloodstream infections will be a net positive for patient care. So it was interesting to read the data Consumer Reports collected regarding central line-related bloodstream infections. In every state, hospitals significantly decreased the number of central line infections that occurred. In fact, many hospitals – several with more than 6,000 central line days – reported ZERO central line-related blood infections. You read that right. ZERO. Zilch. Nada. Absolutely no incidents of central line-related bloodstream infections. The prevention in central line-related infections is credited to a simple five step checklist that was developed by Peter Pronovost, a Johns Hopkins critical care specialist. He felt that public disclosure of infection rates was a powerful motivator for hospitals to reduce the incidence of infections. I agree, to a point, but there is a bigger motivator out there, though. Cold hard cash. Under Section 5001(c) of the Deficit Reduction Act, the Centers for Medicare and Medicaid Services was required to select diagnosis codes that “have a high cost or high volume”, results in higher payment, and “could reasonably be prevented using evidence-based guidelines.” Bloodstream infections related to catheters was chosen as one of these codes and eventually became known as a “never event” – at least alluding to the notion that such infections should “never” happen and making a firm statement that the government would “never” pay for care related to such infections. In law, the concept of incurring liability for the occurrence of an event, regardless of whether that event is within one’s control is called strict liability. Here are come comments I previously made about strict liability in medicine. Faced with public scrutiny and the possibility of being held liable for providing significant amounts of uncompensated care to sepsis patients, hospitals needed to make changes … and they did. So first I’d like to start by congratulating the hospitals in Pennsylvania that made ...

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Healthcare Update – 02-18-2010

See also the satellite edition of this Healthcare Update with more links over at ER Stories. “The health reform bill sucks. Just start over.” – 57% of Americans “Rare” multimillion dollar medical malpractice awards in the news … Minnesota jury awards plaintiff born with cerebral palsy a record $23 million – more than double the previous state record. In other news, hospital CEO decides to hand hospital keys to attorney after verdict is read. Two other patients born with cerebral palsy awarded verdicts of $43.5 million and $77 million respectively. Arizona neurosurgeon found liable for $16.5 million after delaying evaluation of patient who “jolted his back” while riding a 4 wheeler and ended up paralyzed. Law firm of Morelli Ratner allegedly “botches” handling of medical malpractice case, gets successfully sued for legal malpractice, then legal malpractice suit gets overturned on appeal. Now law firm is suing its former client to get back $6000 in fees that it fronted for the medical malpractice case. No mention of a retainer agreement where the client agreed to pay for such fees. A New York City judge blasted the firm for bringing “wasteful” litigation and sanctioned the firm for $6000. Next step? Back to appeals court for more wasteful litigation about the judge’s sanctions for engaging in wasteful litigation. Don’t worry, though. It really has nothing to do with the money. All about doing what’s right for the client and protecting patients, you know. Patient dies in emergency department waiting room 11 minutes after arriving with left side pain. He was called by the triage nurse 3 minutes later. Hospital is being investigated by the Department of Health. The attorney representing the family made the following statement in a hallway outside the hearing: “When you go to an emergency room, it’s not like going to a bakery.” You’re right. I haven’t heard of many multimillion dollar judgments against a bakery, have you? Would this patient still be alive if it weren’t for emergency department closures? An 18 year old Ontario woman was seriously injured when her car was broadsided by another vehicle in snowy weather. The closest hospital had closed its emergency department, forcing the ambulance to travel twice as long to the next closest emergency department (see map to the right). The patient died just before arriving at the hospital. Don’t have an emergency medical problem in Los Angeles. County supervisors decided to drop reimbursement from 27% of estimated fees at private hospitals to 18% of estimated fees for emergency physicians and on-call specialists beginning in July. Come on, you Los Angeles supervisors, where are your gonads? Just pass another referendum forcing the private physicians to work for free so no one will take care of the patients, the private hospitals will all close their emergency departments and open acute care centers, and the patients with emergencies will all pile into county hospitals and die waiting for care because the county emergency departments will all be overwhelmed. Think of all the money you’ll save. If I were an emergency physician in California, I’d be looking for a job in another state. They were medical training videos. Really. Emergency physician accused of storing kiddie porn on his computer. Four year old child dies, but is it from pneumonia or from an overdose of clonidine? Prosecutors argued that the child’s blood levels of the clonidine were “toxic”, but the defense attorneys noted that the levels were far lower than any of the other reported cases in which clonidine caused child fatalities. The defense team alleged that the child died from pneumonia but the prosecution’s expert stated that “Four-year-old children, as a rule, ...

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Got Breast Milk?

A mom is given a newborn baby to nurse during middle of night in the hospital (one of Dr. Wes’ hospitals of all places, too). Only problem was that the mom was accidentally given another family’s infant. The mom then nursed another family’s baby. A nurse walked in the room and was surprised to see mom nursing the wrong child. After learning about the mistake, now mom and her personal injury attorney husband are suing the hospital for more than $30,000. Hmmm. If they’re suing for the value of lost milk, a couple of ounces for $30,000 amounts to about a quarter million dollars a gallon. Comparing breast milk to oil, according to the lawsuit, this mom’s milk would cost $10 million per barrel. OPEC is lucky if it makes $150 a barrel — those guys really need to hire her husband’s law firm. If they’re suing for her lost time, then 10 minutes to nurse the kid amounts to $180,000 an hour for wetnursing. That’s not bad coin, either. Although you do have to consider that her husband’s law firm stands to make about one-third of any judgment, so her potential take home is considerably less. Just another example of why we need a loser pays tort system in this country. UPDATE FEBRUARY 15, 2010 In the comments below, Max Kennerly made an interesting claim. The parents’ lawsuit against the hospital might be able to proceed on a theory of battery. If it is a battery claim, then these poor injured plaintiffs should really be suing the newborn infant for negligent suckling. Why are they suing the hospital? The hospital can’t batter anyone – unless one of its lights falls off the ceiling and konks someone on the noggin. And I’m sure the aide who handed the baby to the mom didn’t offensively touch the mother. Oops. I almost forgot. Battery claims require intent – they’re intentional torts. So the lawsuit still has no business being filed. Come to think of it, I think that the infant’s family should sue the mother. After all, Jennifer Spiegel intentionally shoved her boob in this poor infant’s face, probably scared the hell out of the kid, and could have nearly suffocated him. And she did all this without even checking to see whether or not it was her kid. In fact, the hospital should probably call the Department of Child Protective Services on that lady. Battery. Indecent exposure to a minor. Jail time isn’t good enough for her. Bring back the stockades.

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