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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.

What is an 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

“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

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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Are you smarter than an Orthochick?

The first day of her new PGY year and Dr. Orthochick is already playing “Are You Smarter Than the ER Attending?” on her blog. She describes the case of a patient who had a “right shoulder nerve block” after shoulder surgery and who continued to have weakness and paresthesias in his arm 12 hours after the block was performed. The patient went to emergency department and the ED physician apparently ordered CT scans of the head and neck. Then Orthochick gets called and has to get out of bed at 3AM to do a consult. With the normal CT results in hand, she comes to the conclusion that the testing should never have been performed and that the emergency physician is no smarter than Orthochick’s sister or the patient, both of whom thought that no testing should have been performed (even though the reason the patient went to the emergency department was because he thought something was wrong). Oh, and Orthochick’s ortho attending thought the emergency attending’s workup was funny, too. Orthochick doesn’t say what kind of “shoulder nerve block” was performed on the patient. Bier block? Interscalene block? Axillary block? Orthochick also doesn’t say what kind of anesthetic was used. Most likely Marcaine with epi – which, at least according to the manufacturer (hey, what do they know) declines to insignificant levels during the next three to six hours. Why should anyone have cause for concern when their arm is weak and has decreased sensation six hours after the medicine was supposed to have worn off? Would I personally have obtained CT scans based upon the facts that Orthochick presented? I’m not sure. Orthochick didn’t really provide enough of a history or physical exam to make a determination. Postoperative strokes occur in between 0.05% and 7.4% of patients and Orthochick didn’t give us enough information to determine whether the patient should be more toward the 0.05% or the 7.4% end of the spectrum. It’s not like there are any $15 million judgments against physicians for missing postoperative strokes manifesting themselves as weakness in the right arm or any $1.6 million settlements when doctors were sued after a patient developed numbness and weakness in his arm after surgery on the first pages of a DuckDuckGo search or anything. Yes, I realize that the patients in both of those cases had undergone carotid surgeries and the patient in Orthochick’s post had arm surgery. Not the point. The point is that numbness and weakness in the arm after a surgery can be a sign of a stroke and that in our society there is not much tolerance for missing a postoperative stroke. I’m sure that Orthochick would have been singing an entirely different tune if the patient ended up having had a postoperative stroke and the emergency attending decided to send the patient home without performing any testing. That reminds me. There are all these red colored (at least tn Netter’s Atlas) blood carrying tubes that can get poked, leak, and form harmful collections of blood and there are also these yellow nervey things (at least in Netter’s Atlas) in the neck besides bones and joints that can get damaged when a block is being performed. Another important point is that in the post, Orthochick says that the patient went to the emergency department because “he didn’t realize [the block] was going to last that long.” If the surgeon or anesthesiologist had told the patient how long to expect the block to last or if Orthochick’s teaching residency program had provided the patient with a simple handout informing the patient what to ...

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Going for the Cycle

In one recent twelve hour shift, I saw 31 patients. Of those 31 patients, there were three families. One family had four members to be seen for various medical problems such as a rash for 3-4 years, a medication refill, and mosquito bites. One family had two children who both needed to be evaluated for coughs and who weren’t able to see their assigned family physician until the following day despite a cough duration of 6 days. The third family had two children, one of which had a sore throat and the other that had a “spider bite.” Was it wrong for me to secretly hope that the mom of the two patients in the third family would register to be seen as well so that way I could be one of the select few emergency physicians ever to attain the emergency department equivalent of “the Cycle“? So close …

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Healthcare Update — 06-27-2014

No more donations to the Red Cross for me … Red Cross hires lawyers to block disclosure of how it spent the $300 million it collected to help the victims of Hurricaine Sandy, calling the information “trade secrets.” Bryan Preston warns that however bad you THINK the VA scandal really is, it’s worse. Remember … VA Hospitals aren’t included on the federal government’s Hospital Compare web site Georgia patient charged with stealing discarded needles and medications from a sharps container in the room. Doctor walked into the room to evaluate patient and found “used needles, syringes and vials of medicine were strewn across the floor.” Patient had syringes, used morphine bottles, and various prescription pain relievers in his pockets, states that he was trying to put them back in the broken sharps container. States need federal money to afford to keep psychiatric hospitals open while feds cut payments. 10% of state psychiatric hospital beds closed between 2009 and 2012. Private hospitals have also reduced their psychiatric beds because Medicare and Medicaid typically pay less for inpatient mental health care than for medical care. Good read at USA Today on how several patients learned to cope with their psychiatric illness. Patients overwhelmingly prefer doctors who respond to e-mail, but only 25% of patients would be willing to pay a doctor $25 for the service. The medical director for one of the groups, Dr. Robert Dickinson, stated that e-mail communications with patients are “like online banking.” I disagree. When a doctor provides advice over the e-mail, it usually amounts to providing free medical care. I’m sure that more than 93% of employers would prefer employees who do their work via e-mail without getting paid for it, also. Honey, I’m taking the kids upstairs for a swim in the toilet. Ten percent of all US beaches are “dangerously polluted” and deemed unsafe for swimmers. Most of the pollution is from sewage overflow and stormwater runoff. There’s an intereactive map at the site so you can figure out whether you need to bring toilet paper to the beach to wipe yourself after taking a swim. Price transparency in health care is great, but it may cost insurers money when consumers can compare rates … which is probably why Blue Cross lobbied hard to kill price transparency legislation in Washington State. Opioid use disorders increase significantly in patients prescribed opiates for chronic noncancer pain. Acute dosing raised opioid use disorders about threefold regardless of the dose. Chronic dosing raised risk of opioid use disorders by 15-fold for low average daily dose and by 28-fold for medium average daily dose. Patients chronically prescribed high daily doses of opioids for noncancer pain were 128 TIMES as likely to develop opioid use disorders as those patients not prescribed opioids for chronic pain. Hat tip to @IrfanDhalla via Twitter. Artificial blood showing promise. Haem02 project creates blood that can be stored at room temperature for up to 2 years (currently, all blood donations must be refrigerated) and can be administered to anyone, regardless of blood type. Plus … 4 out of 5 vampires think it tastes great. I’ve been watching too many Supernatural reruns. Great summary article about AC Joint Separations at Academic Life in Emergency Medicine Taking patient satisfaction surveys to a whole new level. American Board of Internal Medicine now wants patients to rate their physicians as one potential prerequisite to the physician sitting for board recertification. So hospital administrators aren’t the only ones who are clueless about statistical significance and statistical bias. The ABIM is being run by idiots. Dear Mr. Smith: You’re gym membership lapsed, ...

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