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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.

Nurse Acquitted

Anne E. Mitchell, the Texas nurse who had been charged with a felony for reporting the actions of a doctor to the state medical board, was acquitted after a jury deliberated for less than an hour about the case. Her attorney focused everyone on the pending litigation that Ms. Mitchell and the other accused nurse have against the county, the hospital, the doctor, and other officials. “We are glad that this phase of this ordeal has ended and that Anne has been restored to her liberty … but there was great damage done in this case, and this does not make them whole.” Go get ’em.

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Healthcare Update 02-10-2010

Screw the client. According to the headlines of this news release (see above), juries have just started awarding verdicts directly to medical malpractice law firms, not to the patients who suffered the injuries. Foreshadowing? More hospitals jumping on the “no dialysis for you” bandwagon. As they refuse to provide outpatient dialysis for patients, they have seen their emergency department visits increase. Dialysis patients showing up in Grady Hospital’s emergency room receive dialysis only in “life-or-death situations.” One Las Vegas hospital saw its number of emergency department visits for dialysis-related issues more than double in 2009. Now the hospital spends $700,000 per month providing dialysis services in its emergency department. Doing some simple math, if the hospital spends about $8.4 million/year on emergency dialysis now, its costs have gone up by about $4 million in the past year – just for dialysis-related medical problems. In this hospital, the total number of emergency department visits for dialysis was 243, meaning that each patient gets about $35,000 per year in medical resources. Ever wonder what kind of calls come in to a poison center’s hotline? Read the Illinois Poison Center’s blog and find out. 35 calls between midnight and 7AM. Some interesting, some sad issues. Those of you from Illinois who want to help keep the poison center in business can also use a link on the site to send an e-mail to Illinois’ governor or add a donation. Guarantee: Get seen in this emergency department within 15 minutes or your visit is free. The catch is that the clock starts ticking “after you finish your paperwork.” I would be interested in seeing how this system is implemented. It appears that they have the opportunity to cherry pick paying patients and filter out the patients who don’t have the means to pay before they put themselves on the hook for free services. “Sorry, ma’am, but part of the paperwork included with patients who have no insurance is a $200 co-pay and a satisfactory medical credit check. What’s that? No co-pay? You’ll need to go to the ancillary paperwork department. The emergency department is new and there are only 8 beds. When it gets busy, the slow lady in the lunch line for non-emergent cases will probably be the long waits for the paperwork to be finished. I give them 9 months before they repeal the policy. Until then, the concept looks like it is bringing them a lot of good PR. I mentioned this case in a previous Healthcare Update, but now it is going to trial. Will criminal charges against nurses who reported a physician’s actions to the Texas medical board affect the willingness of others to report actionable physician behavior? Interesting discussion in the comments section at Overlawyered.com. Emergency visits in LA suburb more than double in less than 10 years. Of those patients, 50% have Medicaid, 30% are self-pay (where hospital collects less than 5% of bills), 10% are Medicare and 10% have other insurance. Will increased volumes offset lower payments? Less access to health care for NY citizens. St. Vincent’s Hospital in New York closing due to massive debt. Meanwhile, Deaconness Hospital in Indiana is expanding its emergency department. That way, when nursing homes send patients there and refuse to take them back, the patients will have a place to stay. Edwin Leap has an all-too-appropriate post about what message boards in the emergency department should say. Some of the good ones: ‘Sorry about the wait, but after all, your symptoms started 10 years ago, right?’ ‘We can access your recent narcotic prescriptions online. Creepy, isn’t it?’ ‘If you ...

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I don’t rant a lot about my personal life, but tonight you’ll have to bear with me. I’ve had problems with chronic pain due to a disease I have. It comes and it goes. Some days I hardly realize it’s there, sometimes it is significant. The past couple of days have been particularly bad pain days. I went to bed last night and Mrs. WhiteCoat was trying to talk me to going to the emergency department as a patient and I basically told her that would not occur unless one of my vital bodily functions ceased to function. Even when trying to hide the pain, I had difficulty moving around and difficulty finding a comfortable position. A few ibuprofens gave me a sour stomach, but took the edge off the pain enough for me to fall asleep. Today was a little better until I tried to put on a shirt. When I reached over my head, I felt like someone shanked me with a hot knife. I couldn’t take a deep breath and started wondering whether or not I had collapsed a lung. Slowly the pain died down to the point that I could move again. I sat at the computer and typed out a few e-mails, shallow breaths and all, trying to find the position that caused the least amount of pain. When I was done, I had to decide what to try to do with the rest of the day. I took our new dog outside for a little walk in the snow. Watching him run around and flip snow in the air with his nose took my mind off of me. By the time we got back, I decided to shovel the driveway. Yeah pushing the shovel hurt at first. As I tossed the snow in the air, the dog started to jump up and bite at the snow in the air. I started to laugh. Then he started to run along side the shovel and bark at the snow. I started flipping snow at him randomly as I was shoveling. He jumped up in the air and flipped backwards into the snow banks biting at the snow I had flipped in the air. Before I knew it, half the driveway was finished and the dog was running in circles in the yard like he had just snuck a couple of Red Bulls out of the fridge in the garage. Funny thing happened. The pain was better. Don’t get me wrong. I still hurt. But when the kids came home from school, I wasn’t chewing a hole in my lip when I gave them hugs and had them sit on my lap to tell me how their day went. Sometimes the less you dwell on pain, the less you have pain. Goes back to the difference between life and living. You have to live your life, but you do it living with a disease, not living for a disease. Sometimes it does you good to tell the disease to get lost for a while.

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When you’re driving down the field in opposing territory in the fourth quarter with more than three minutes left, why would you ever throw a pass? Keep to the ground game and run down the clock so they can’t get the ball back and have time to drive down the field and score again. If Manning hadn’t thrown that horrible pass that got picked off by Tracy Porter and returned for a touchdown, the Colts would have undoubtedly won the Super Bowl. The whole Indianapolis Colts football team and their fans were irreparably damaged by Manning’s negligent actions. Sound crazy? This Monday morning quarterbacking is the same thing a lot of doctors go through when they make a judgment call and are sued for malpractice due to a bad outcome. I wonder … can fans who lose money on bets on a pro football team sue the professional football players for their negligent decisions? I bet those multimillion dollar salaries could pay for a lot of damages.

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On Nursing Home Transfers and Liability Reform

Several times in the past few days we have gotten ambulance runs from the nursing homes in the middle of the night to evaluate elderly nursing home patients for “unresponsiveness”. When the “unresponsive” patients arrive, they are at their baseline mental status and, after the obligatory workup to rule out the bad causes of “unresponsiveness,” nothing is wrong with them. Is “unresponsive state – rule out REM sleep” a legitimate discharge diagnosis? Then, last night we got an 82 year old COPD patient by ambulance from a nursing home who was having “severe shortness of breath” and “hypoxia”. Her oxygen saturation was in the 70s in the nursing home (normal is in the 90s) and she was “dusky,” prompting the ambulance call. When she arrived by ambulance, with her usual oxygen settings on the nasal cannula, her saturation was a respectable 92% – an acceptable value for a COPD patient. Was her shortness of breath and hypoxia due to some acute underlying medical disaster? Fortunately, I like to talk to the EMTs when they bring in the patients. In this case, the patient’s nurse told them that the patient took off her oxygen to go outside and smoke a cigarette in the cold. She enjoyed the first cigarette so much that she had a second – while her oxygen canister waited longingly for her inside the nursing home. She may have gone for a third and turned into a smokesicle, but her nurse noted the lonely oxygen canister in the hall and investigated, finding the patient standing out in the cold. Now of course none of this was written in the transfer papers and we had to call the nursing home to verify the story. The patient’s nurse had left for the evening and the nurse that was there had no idea about the patient, so we had to call the previous nurse on her cell phone at 11:30 at night. She didn’t answer her cell, so we had to call her house. Oh, and don’t forget the obligatory emergency department testing just so that we can prove that the patient really is at her baseline before sending her back – just in case she wakes up dead the next morning. All this because granny wanted a couple drags from a Marlboro. Kind of ridiculous, huh? Although I get frustrated by what some people perceive as “bullshit nursing home transfers,” I also find myself bowing to the same pressures that nursing homes have when I see the patients in the emergency department. How often does any emergency physician look at a frail elderly nursing home patient who complained of shortness of breath and not order any testing? I’ve done minimal workups on some patients (including Granny Marlboro above) and have had people tell me that I am lugging a couple of coconuts around in my scrub bottoms for not doing a million dollar workup on all the nursing home patients … and even for sending the patients back to the nursing home when they come in with vague complaints. If a patient complains of shortness of breath in the nursing home and the nurses don’t send the patient for evaluation, the nurse and the nursing home will be investigated by all the clipboard brigades and would likely be sued if the patient suffered a bad outcome. Similarly, if I don’t do a thorough emergency department workup on a nursing home patient with a vague complaint of shortness of breath or weakness or fleeting chest pain and the patient has a bad outcome after their emergency department visit, all the people ...

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When Will We Learn?

Hey, its ERP from ER stories doing a guest rant post. OK, I have blogged about this before, but nearly every shift, I have cases which emphasize the need to repeat myself. When the hell with doctors learn to stop obsessing about hypertension?  I don’t mean to say that we should not treat it – of course we should. I am talking about blaming every symptom a patient is having on it.  I am talking about aggressive lowering of the BP in the acute setting.  It is just stupid. If I had a nickle for every time a patient’s headache or dizziness is attributed to hypertension I would be a millionaire.  The sad truth is that it almost never is!  The BP is a REACTION to the symptoms not the cause.  This is obviously true in people who are chronically hypertensive – it took years for them to develop it so why do we think we need it lowered in 5 minutes?  Of course their pressure will go up to 200 when they have pain.  And guess what, lowering it fast will probably make new problems – like syncope and rebound hypertension caused by crappy old drugs like Clonidine. This is different than when a young person has hypertensive encephalopathy or when someone has a big head bleed (where you want to lower the pressure only a small amount) or an aortic dissection.  They people do need IV treatment but almost no one else does! I just had a patient who was admitted to three days in England (where he was visiting I assume)  for “hypertensive emergency” because he was having a room spinning sensation and a systolic pressure of over 200.  Guess what, they lowered his pressure and gave him new drugs to go home with but he still had dizziness! Why? He had obvious benign positional vertigo!  I gave him antivert (an antihistamine that works well for it) and it went away!   And as a bonus, his pressure came down on its own! So, patients do not check your BP when you feel pain or dizziness (unless you are on the verge of passing out – in which case you are looking to see if your BP is LOW), check it when you feel normal and have been chilling out for 10-15 minutes.  Do that over several weeks and show the numbers to your doctors and let him or her decide treatment. Doctors, do not attribute every headache, vertiginous episode, or other discomfort referable to the head to hypertension.  Do not agressively lower it in the ER or your office and then discharge the patient.  Do not give someone labatelol because the have a nose bleed.  Do not fail to examine someone and miss benign positional vertigo.  Don’t just treat the number to make yourself feel better!  Treat hypertension for the long term!

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