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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.

The Hospital Rodeo

A patient gets brought by ambulance for suicidal threat. He’s going to “slit his motherF’ing throat.” When he is brought in, he is still slurring his speech and you get a buzz when he breathes on you. We told him that he has to be admitted for stabilization then sent to a psych institution (psych transfers are another issue – ill go into that on another rant). Well the patient doesn’t want to stay in the hospital. He had a job interview the next morning. He gets uppity with the nurses and starts swinging, so he gets to try on some complimentary leather wrist bracelets. We’re getting all of the stuff together to put in an IV and draw blood and he starts screaming “Stop this shit. Stop it. You’re all just doing unnecessary shit to me to run up my hospital bill.” Then he began flexing his muscles trying to break through the leathers. Everyone just stopped and watched for a few seconds. It was almost like a mime routine. He pulled out all of the slack in the leathers and then just strained. His face got red, but his arms didn’t go anywhere. After the Marcel Marceau imitation was finished, he finally figured out that he couldn’t break a leather restraint, so then he started shaking the bed back and forth. Reasoning with him didn’t work. So to protect him and the staff, we decided to put him to sleep with a little Haldol. While the nurse was putting in the IV, the patient asked “what’s that?” We told him. Then he went back to shaking the bed. Then the nurse flushed the line with saline. The patient asked “what’s THAT?” We told him. Back to shaking the bed. Then came the Haldol. The patient stopped and yells “now what’s THAT?” The nurse says “it’s a psychiatric medication called Haldol … and its REALLY expensive.” Great. Thanks, Tony. All of a sudden, it turns into … “Welcome to the first annual Hosptial Rodeo, ladies and gentlemen. In room 6 we have ‘Bucking Budweiser.’ Boy, something sure shook him up. He just bucked two riders off of him and nearly flipped the bed over. He’s snorting and hollering like nothing I’ve ever seen before.” “Yeah, Jim. Maybe he got stung by a bee or something. I sure pity the next person who tries to calm him down.” Fortunately, IV Haldol works quickly and the rodeo ended as quickly as it started. The real fun was trying to transfer him.

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Doctor Shopping

Did some searching about healthcare fraud and just read about a new law passed in Tennessee. According to this news station, it is now a felony to deceive a physician to get drugs. The last quote in this article shows how doctor shopping affects everyone: “[Doctor shoppers] are taking up the time of our very important professionals who need to see patients who truly need their care.” This needs to be a national law. Now. Here are some more articles about the Tennessee law and about “doctor shoppers”: http://www.bizjournals.com/memphis/stories/2007/07/23/daily22.html?surround=lfn http://state.tn.us/finance/newsrel/doctor_shopping.html http://www.fda.gov/fdac/features/2001/501_drug.html http://www.mja.com.au/public/issues/180_05_010304/kam10498_fm.html

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Slow ventricular tachycardia

Among the many patients waiting for a telemetry bed was a rather large gentleman with a history of heart disease and arrhythmias. He was sitting in his bed eating dinner when the resident went to re-evaluate him. As the resident approached the patient’s bed he became concerned with the tracing on the monitor. In a nervous voice he yelled across the ED “Dr. Whitecoat! Come quick! The patient in Bed 8 is in slow ventricular tachycardia!” One of my favorite nurses raised her eyebrows and saw that the patient was busily finishing his peach cobbler – oblivious to the frantic calls for help. She slowly sauntered toward the patient’s bed. As I poked my head out from behind Curtain Number Three, my hands full of blood from the squirting dialysis graft, I saw the nurse do a U-turn in the hall, shake her head, and mutter over her shoulder “that’s the pulse oximeter you dumbass.” The resident looked at me, shrugged his shoulders, and said “I’m so embarrassed.” I really do love my job (and the people I work with).

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Waking "Unresponsive" Patients

Ever have a patient who is brought in “unresponsive”? You know — the ones who blink their eyes when you touch their face and the ones whose hands always seem to drift to the side when held over their face and dropped. How to wake them??? Here’s a list of techniques that have been suggested by various authorities on the matter. Painful stimuli are the most commonly used techniques. Sternal rubs, pressure to the nailbeds, and pressure to the supraorbital nerves have all been employed. One authority related the story about a patient who would not get off a stretcher when brought to the ED by an ambulance because the last time he came there unconscious the “motherf***ing doctor punched me in the chest and left a bruise.” Translate that into “the physician performed a vigorous sternal rub that brought the patient out of his unconscious state.” Ammonia inhalants sometimes work – until the patients hold their breath. Do not stick one inhalant in each nostril and squeeze. Doing so could cause chemical burns. Dripping water on the forehead or eyes also seems to work fairly well. This one has few side effects, but either dress in protective gear or have a towel ready in case the patient suddenly wakes up spitting. One authority suggested inserting a cotton swab down the patient’s nostril. The authority stopped performing this maneuver when one patient suddenly turned her head to the side and the cotton swab snapped off in her nose. Fear Factor: Saying in a loud voice “OK, lets cut the clothes off and put the catheter in the bladder” also seems to work. One expert on the matter related a story about a gentleman who was chronically intoxicated and repeatedly came to the emergency department “unconscious.” The paramedics repeatedly cut off his clothing, including his winter coat, in order to assess for occult injuries. After the patient sobered up, the ED staff would call his parents and tell them that he needed a set of clothing and a ride home. At one point the patient’s exasperated father politely asked “would you please stop cutting off his clothes . . . we have bought seven new coats in the past two months.” Any new techniques we are missing?

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Mr. Wayne

We had a well-known patient return for evaluation yesterday. He has some challenging complaints on previous visits. Looking through his history, below are some of the more memorable complaints. Yes, his name has been changed. Touched compressor with petroleum on it. Touched same hand to mouth and got diarrhea. Wanted to know if he was poisoned. Walking past janitor with open bottle of water, janitor jerked bucket and blue disinfectant splashed onto open water bottle. Thinks that disinfectant may have gotten into his water. Took one sip, didn’t taste anything. Took another sip thought it may have tasted like disinfectant. Called poison control which allegedly couldn’t tell him if he was poisoned or not. Wanted to be tested for disinfectant poisoning. Aciphex taken 4 hours and 10 minutes too soon. Wants to know if he could have any bad effects from it. Drank water out of styrofoam cup and had burning to the back of his throat. Drank water from several other styrofoam cups and still had burning to throat. Brought cups into be tested for poison. Sent home from ER. Seen in physician’s office following day and given nystatin rinses. Purchased ham sandwich out of vending machine in basement of hospital. Had packet of mayonnaise wrapped inside, and put on sandwich, but thinks mayonnaise was warm and may have poisoned him. Walked by nurse in hall who was shaking an IV bag to mix contents. Thinks that some of contents may have sprayed onto him and contaminated him. Came to ER twice within 24 hours for nausea. Given GI cocktails on both occasions. Came back third time to ask if that was too much medicine to take in 24 hours. Ate “soggy” hamburger at local restaurant because he was hungry. Came in late at night because he didn’t think he should have eaten hamburger when it was soggy. Given glass of water in ER after given GI cocktail. Said it tasted like alcohol and wanted to know if we were poisoning him. Opened piece of gum and began chewing it. Thought gum tasted like metal. Came in to see if he swallowed tin foil. Ate can of Campbell’s soup that tasted too “tangy.” Came in two weeks later for eating another can of Campbell’s soup that tasted too tangy. Came to be tested for dehydration. Physician told him that only way to do so was to insert Foley catheter to measure urine output. Left without further treatment. Licked scissors with something on them. Washed lips with Coast soap and then thought he poisoned himself with the soap. Called poison control and was told that people could definitely poison themselves with Coast soap — he should only use Dove soap. Twitching more than usual. Took Maalox and Prilosec at same time. Feels sick. Cleaning refrigerator and got cleaner fluid on hands. Thinks he was poisoned. Constipated, drank cup coffee, now has diarrhea. Ate piece of turkey, accidentally ate “red stuff” near bone along with it. Feels nauseous. Thinks turkey wasn’t cooked all the way. Called Poison Control and told not to worry. Came to ER at 3AM on Christmas night to be checked anyway. Given bottle of amoxicillin for infection. Took tin foil seal off, but there was still some sticking out off of the edge of the bottle. Brought bottle in and thought he may have swallowed tin foil. Nurse asked him if he was drinking pills out of the bottle. He replied “no.” Nurse asked him how the metal would have gotten into his mouth. Stated he “might have poured some of it out” (no, this didn’t make ...

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Hospitals Getting Graded Using Wrong Test Questions

So the Department of Health and Human Services’ “report card” grading hospitals on how well the hospitals “care for all their adult patients with certain medical conditions” just keeps getting worse and worse. Now we’re seeing that the “quality indicators” the government is using are nothing of the sort. One recent study shows that at least one set of “quality indicators” Increases the likelihood of misdiagnosis, Causes patients to receive unnecessary antibiotics, Has no effect on patient length of stay or death rates Not mentioned in the article, but just as important – increases the costs that patients have to pay due to all the unnecessary antibiotics and blood cultures Jumping through all the government hoops makes patients more likely to be misdiagnosed and more likely to receive unnecessary antibiotics. And they’re the ones grading the hospitals? The HHS home page states “This information will help you compare the quality of care hospitals provide.” Funny thing . . . if you look around on the web site, it shows nothing about where the quality indicators came from or what scientific methods were used to come up with the indicators. This page lists all of the quality indicators that HHS uses to determine whether or not patients are receiving “quality care.” If you go to the Pneumonia “Process of Care Measures” you’ll see that HHS thinks that “quality hospitals” give antibiotics within 4 hours because “Timely use of antibiotics can improve the treatment of pneumonia caused by bacteria.” Great. So why the 4 hour time frame? There are no data on the web site to support the government’s “quality indicators.” Now at least one study shows that the 4 hour time frame may actually harm patients. And why does HHS equate quality of care with giving unnecessary antibiotics to patients with viral pneumonia? Some of the quality indicators are valid. But let’s not use smoke and mirrors to coerce hospitals into providing unnecessary and potentially harmful care so that they can be at the top of some report card. The patients in the US deserve better than this. On tap in the future – more than 100 new “quality indicators” by which hospitals will be expected to abide. Just how many of them will have a scientific basis? I’m not keeping my hopes up. This micromanagement is going to make healthcare in the US more expensive and less effective. One more thing – has anyone ever noticed that government-run hospitals aren’t on the HHS “Hospital Compare” website? Try searching for Walter Reed Army Medical Center or Tripler Army Medical Center, for example. If civilian hospitals are performing as well as government-run facilities, they should get a great grade, right? Why aren’t government-run hospitals available for comparison? Bottom line: If everyone ignores these indicators, they become meaningless. No quality indicators for the Department of Health and Human Services leadership . . . yet.

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