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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.

No More Dr. WhiteCoat?

An article in the New York Times made me shudder. No more white coats? According to a new study in the Journal of Infection Control and Hospital Epidemiology, there are now “guidance statements” about what health care providers should wear in the non-operating room hospital setting. The study discusses the available evidence regarding contamination of hospital attire with bacteria. Many studies show that there can be bacteria on a medical provider’s clothing – including scrubs, ties, and white coats. The authors then surveyed hospitals to determine policies related to the attire of health care providers. Out of 337 respondents, 65% believed that a health care provider’s attire was somewhat important or very important in the transmission of pathogens, yet only 11% of respondents enforced an attire policy. The authors didn’t state whether the survey respondents had any familiarity with the studies on clothing and transmission of pathogens, so the questions on the survey could very well have been leading in order to get the desired answers. The authors repeatedly note that there aren’t enough studies to make firm recommendations: “There is a paucity of data on the optimal approach to HCP attire in clinical, nonsurgical areas” “Appropriately designed studies are needed to better define the relationship between HCP attire and HAIs” “No clinical data yet exist to define the impact of HCP apparel on transmission” Yet despite this lack of evidence that clothing transmits infections to patients and despite a review of literature by Wilson et al. performed in 2007 showed that “the hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by existing evidence”, the study authors then turn around and create a laundry list [no pun intended] of “guidance statements” designed to … prevent health care workers from transmitting infections to patients. “Studies” and the resulting unsupported recommendations such as this one are a huge problem in medicine right now. The Joint Commission manufactures similar junk science all the time – creating patient safety recommendations without one shred of evidence to support them. Their heads would implode if they had to substantiate the bases for all of their “patient safety goals.” Scientific evidence? Who needs scientific evidence? I just wrote about the same issue regarding “strong” recommendations for tPA use in stroke despite a collection of studies showing that tPA does more harm than good. Now a group of doctors representing prestigious universities all over the country is making “guidance statements” regarding hospital attire when they have NO scientific evidence for their “guidance.” Wash clothes? Fine. I don’t want bodily fluids on my white coat any more than patients want to see it there. Recommend further issues that need scientific studies? Good job. Let’s look into them to see if they make a difference in outcomes. But if you don’t have scientific evidence supporting your recommendations, then STOP MAKING THE RECOMMENDATIONS. Sorry, but I refuse to be called Dr. BareBelowTheElbows based on puffery and innuendo.

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Healthcare Update – 01-30-2014

More medical news from around the web over on my other blog at EP Monthly. The nice thing about regulations is that they can easily be fixed by more regulations. Timeouts for simple ED procedures. Site verification for abscess drainage. Waste of time in the ED. Stickers on glass doors. Expired clocks. Computers on the floor. These are some of the inane “violations” various Joint Commission surveyors have uncovered. All of the time addressing and documenting these “safety issues” adds up and eventually detracts from emergency department throughput. To solve that problem, the Joint Commission has created even more standards to address hospital boarding and ED throughput. Unfortunate complications after tonsil surgery cause cardiac arrest and brain death in 13 year old girl. Now she’s been transferred to a long term care facility and had a tracheostomy and feeding tube inserted. Mother refuses to believe she is dead. Meanwhile, idiots like Nancy Grace stoke the flames, insinuating that the doctors might not have told the truth about the patient’s brain death and later stating that the patient who really wasn’t brain dead might have a “Lazarus” moment and come back from her [undead?] state. So which is it, Nancy? Either Jahi’s dead and the doctors are right or she’s not dead and your “Lazarus” comment makes no sense. Actually, it makes no sense anyway, but only shows that you’ll apparently say anything for ratings. CNN needs to dump this woman. Glad she has at least toned down her rhetoric a little bit so this poor girl’s family can grieve in peace. Anesthesiologist sues former insurer and former employer for emotional distress and former defense attorney for legal malpractice after attorney acts in best interests of employer, but fails to introduce evidence regarding actions of a nurse that allegedly would have exculpated the doctor. Conflict of interest in malpractice cases is a HUGE problem. If you are named in a lawsuit and have any doubts about whether your attorney is acting in your best interests, then you have the right to request your own personal counsel. Do it … in writing. Tragic case of a chest pain patient dying after being misdiagnosed. Went to emergency department two days in a row for chest/abdominal pain radiating to jaw and mouth. Had negative cardiac workups done on both visits and was discharged once with heat exhaustion and the second time with “stomach flu.” Collapsed hours after the second discharge and was returned to the hospital where an aortic dissection was diagnosed. He died shortly after surgery to repair the dissection. This same difficult-to-diagnose disease took the life of John Ritter. Chinese patient upset over his nose job goes to hospital, stabs three doctors. One doctor dies. Now a court has sentenced patient to death. When Obamacare imposes extra costs on insurers, insurers fight back by limiting their pool of physicians. United HealthCare drops many doctors from its Medicare Advantage plan, leaving patients with “insurance,” but few doctors to provide the medical care. “Affordable Care“? Perhaps for the insurers. When Obamacare imposes extra costs on insurers, insurers fight back by limiting their pool of physicians. United HealthCare drops many doctors from its Medicare Advantage plan, leaving patients with “insurance,” but few doctors to provide the medical care. http://www.weeklystandard.com/blogs/hundreds-ohio-lose-their-doctor-due-obamacare_775213.html I may have been wrong about the “Affordable” “Care” Act. Premiums for a healthy non-smoking 30 year old woman in Vermont are only $56 per month – that’s only $672 per year! I pay three times that every month for my family. Wait. What? The deductible for that coverage is $100,000? One HUNDRED THOUSAND dollars? And ...

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Angry Betty and the Unresponsive Kid

The nervous voice on the call over the radio already sounded bad. “Emergency One en route to Interstate 88, mile marker 177 for report of car on side of road with parent witnessed performing CPR on child.” CPR on a kid? Damn. Kids aren’t supposed to need CPR. There was an eerie silence at the nurse’s station as everyone waited for the next radio report. Finally it came. “Metro General, this is Emergency One. Do you copy?”You never think much about how much information can be inferred from the tone of a paramedic’s voice until you’re in a situation like this. In this case, the paramedic was calm and taking his time. As soon as they heard his voice, three nurses, a secretary, and two doctors let out a sigh of relief. The nurse picked up the radio microphone. “This is Metro General, go ahead.” “Metro General, we have a ten year old male with no local doctor who reportedly had a witnessed cardiac arrest while driving on the highway with his parents. He regained a pulse after his mother performed CPR on him for a minute or so. Mother is a cardiologist and is accompanying us on this transport. ETA is 6 minutes. Over.”Everyone looked at each other. Female cardiologist? Nahhhh. It couldn’t be her. Not Angry Betty. Whenever you had a patient with chest pain, you HOPED that Angry Betty wasn’t on call. No matter what you said, she’d always disagree with you and then talk down to you for not knowing your stuff. Then she’d ask some esoteric and often irrelevant fact that you never were able to answer quick enough and she’d nose breathe into the phone for what seemed like an eternity while you looked for the answer.Sometimes you’d get all the labs laid out on the desk in front of you just to try to beat her.  “How stenosed was the RCA on his last angiogram and what was the date?”“40% on October 13” [fist pump in the air]“When was his last ophthalmology exam?”“June 2012” [HA! Double fist pump]“What was the last homocysteine level?” “Ummmm. Hold on.” [eyeroll … she won again][constant blow of air into the receiver of the phone]“I don’t see one in the computer.” “You don’t see one or it was never done?”“Well I can’t see what was ordered at other facilities, but there hasn’t been one done at this facility.”[more nosebreathing]“I’ll order it.”Six minutes later, everyone’s fears were realized. Paramedics wheeled in a stretcher with a 10 year old boy playing on his iPad. Angry Betty was running alongside of the stretcher with her stethoscope glued to his chest.“Your patient,” says the other ED physician working that day.“No. YOUR patient.”“Sorry, I’m going on break.”“OK, paper/scissors/rock.” Figures. I lost that one, too. “Hi, Dr. Angry. What happened with Angry Junior today?”“We were driving on the highway heading downtown when I looked in the rearview mirror and Junior was unresponsive.”“Unresponsive?”“Yes. Unresponsive. His mouth was open wide and his eyes were closed. I yelled his name and he didn’t answer. I had his sister slap his face and he barely flinched. So I pulled over, started CPR, and called 911.”“I see.”“By the time these paramedics arrived, he had return of his circulation. They did an EKG in the ambulance that was normal, but based on the symptoms, it appears cardiac in nature.”I looked at Angry Junior. He looked up from his iPad and shrugged his shoulders. “I see.”“What happened to you?” I asked Angry Junior.“I think I fell asleep,” he responded.Angry Betty interrupted. “You did NOT fall asleep. You were unconscious and difficult ...

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Medicaid Emergency Department Reimbursement Rates

Ever wondered how much doctors get paid for taking care of Medicaid patients? I came across some data compiled for Medicaid reimbursement for emergency department visits from 2011. You can download the .pdf file here. There was also some information from 2008 and the rates hadn’t changed much. For each category, the payments are broken down into CPT codes depending on intensity of service. A 99281 code is essentially a nurse visit – no doctor involvement and hardly ever used A 99282 is a simple case with no or minimal physical exam – such as an asymptomatic patient needing a medication refill or perhaps a simple sunburn. A 99283 is a straightforward case with little medical decisionmaking such as an ear infection, a strep throat, or a UTI A 99284 case requires more decisionmaking with some lab tests being ordered. Perhaps a patient with a sprained ankle, a patient with minor abdominal pain, or a patient with asthma needing nebulizer treatments. A 99285 is a case requiring high medical decisionmaking, multiple tests, and likely hospital admission. Consider cardiac chest pain, severe abdominal pain, suicidal patients, patients with low blood pressure, etc A 99291 is a “critical care” code, meaning that the patients are in danger of dying or having severe health issues. Consider patients requiring CPR, multiple drug overdoses, uncontrolled psychiatric patients, patients with arrhythmias, etc. Finally 99292 is an “extended critical care code” meaning that if a doctor spends more than 90 minutes stabilizing a patient, then the doctor gets paid this amount in addition to the 99291 amount. What does this data show you? Based on their payments to physicians, New York and New Jersey seem to put very little value on the lives of their citizens. They’ll pay doctors as little as $58 to save your life and spend up to an hour and a half keeping you alive. Malpractice insurance costs more than that. Hell, parking your car in a garage in the Greater NY area to go to work in the hospital costs more than that. Rhode Island is even worse. It pays emergency physicians a whopping $29 to provide up to 90 minutes of critical care. Michigan and Wisconsin are also on the list of pathetic payors. When patients who get their new Medicaid “insurance” cards under Obamacare wonder why they can’t find anyone to provide them care, the fact that many states pay doctors less than the cost of caring for Medicaid patients would be one of the reasons for this lack of access. Remember: Healthcare insurance doesn’t guarantee you access to medical care any more than automobile insurance guarantees you access to a car.

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Bosch Dishwasher E 25 Error Message

This is a completely non-medical post that will be of no interest to 99% of the regular readers of this blog (maybe a little interest if you want to see how I fixed my dishwasher), but I wanted to put it up for the search engines to help anyone try to fix had the same problem that ate up a few hours of my day. When our previous dishwasher died on us last year, we spent a little more money on a Bosch dishwasher. So far, haven’t had too many complaints about it. On the pro side, it is quiet and it gets the dishes quite clean. There also isn’t a water jet spinning around above the top rack, so you can fit larger items up there. On the con side, there isn’t as much space for plates on the bottom. We have trouble fitting a day’s worth of dishes from our 6 person family inside. And there’s no way you’ll get a large pan in there unless you take up the whole upper rack. So I wouldn’t recommend a Bosch dishwasher for a larger family. The warranty on our dishwasher was for 12 months. Unfortunately, a problem developed at 15 months. Every time the dishwasher started up, it would run for a little while, then it would stop and flash an “E:25” error message. Mrs. WhiteCoat called the service line. The “E:25” code meant that there was an outflow blockage of some sort. For a minimum $125 charge (not including parts and labor) they could send a technician out in about 5 days. I like working with cars and other mechanical things, so when I got home from work, I figured that I would take the dishwasher apart and see if I could figure out what was wrong. I pulled apart the drainage apparatus from inside the dishwasher. There was a lot of sludge and debris there. That could be blocking the flow of water. Mental note to clean that stuff out more often. Cleaned everything out and reassembled the drainage apparatus and started the dishwasher. Still got the same error message. So I *turned off the electricity to the dishwasher at the breaker box first*, then I pulled the dishwasher out from under the counter. In the pictures, the dishwasher is laying on its right side. I removed the clamp on the drainage hose and let the water inside drain into a plastic bowl. Then I tried blowing through the drainage hose, figuring that if there was a blockage between the hose and the sink, I wouldn’t be able to blow air through it. Air went through the hose fine. I put my hand around the edge of the hose so I wasn’t getting slime in my mouth and it still didn’t taste very good, but air went through the hose fine. So I knew that the problem was with the drainage motor or the impeller. I pulled off the drainage motor by prying up a couple of clamps on the side and twisting the housing. Inside, I found the problem. There was a chip from a piece of a plate stuck in the drain. I pulled out the chip, reassembled the drainage motor assembly, turned back on the electricity, and ran the dishwasher through a cycle. No more error message. The chip from the plate was too large to pass through the drainage pipe and was either causing the water to back up or it was blocking the impeller and keeping it from spinning. Hopefully this little description helps someone else out there. If so, please leave ...

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Antibacterial Soap Latest on FDA’s Hit List

The Washington Post recently published an article showing how an antibacterial chemical in soap is now on FDA’s hit list. The FDA is reportedly going to require that manufacturers prove antibacterial soaps are safe and more effective than regular soap and water. The problem that I had with the FDA’s request for more research to prove the safety and efficacy of triclosan, the ingredient under scrutiny, was that a PubMed search shows 1915 articles using the keyword “triclosan”. What more research does the CDC want? According to an FDA Consumer Update triclosan has “altered hormone regulation” in animals and other studies [not cited in the FDA update] have “raised the possibility” that the chemical may make bacteria resistant to antibiotics. First of all, I’m not going to take sides on whether using antimicrobial soap is always a good or bad thing. Personally, I think that using it under circumstances where there is greater risk for transmission of disease is appropriate. Cutting up raw chicken? Use antibacterial soap afterwards. Changing a diaper full of foul-smelling diarrhea? Ditto. Hospital patient contact? Maybe. ICU patients? Probably. Post op patients? Yes. To me, it ends up being a judgment call. If there’s no harm in using it, what’s the problem? So let’s look at some data. Research Already Shows Triclosan is Safe and Effective Below are just a smattering of the studies I found demonstrating the safety and effectiveness of triclosan. Remember that triclosan has been approved for use since 1972. This 1989 study showed that triclosan was safe for use in mouthwash and toothpaste. This August 1999 study showed that both 1% triclosan and 4% chlorhexidine were effective at reducing pathogens on hands in a surgical unit, but that triclosan also killed MRSA while chlorhexidine did not. This April 2000 review showed that triclosan “is a widely accepted antimicrobial ingredient because of its safety and antimicrobial efficacy” and “has demonstrated immediate, persistent, broad-spectrum antimicrobial effectiveness and utility in clinical health care settings.” 2% triclosan was shown effective in reducing MRSA skin colonization (where the organism is present on the skin but is not causing an “infection”). 1% triclosan was used in one Australian study to cause a “highly significant reduction” in the number of MRSA carriers and infections in a Cardiothoracic Surgical Unit. Adding .3% (or 0.3% if you’re following some inane Joint Commission rules for medical charting) triclosan to handwashing and bathing soaps caused an “immediate termination” in the acute phase of a MRSA outbreak in a nursery and maintained the MRSA-free status for more than 3 years. 1.5% triclosan soap decreased the spread of shigella as compared to plain soap and water when used after changing diapers of babies with diarrhea. And although not a study involving hand soap, this 2013 study showed that when sutures coated with triclosan were used during colorectal surgeries, the incidence of wound infections was cut in half. Claims That Triclosan “Alters Hormone Regulation” Are Speculative Triclosan is somewhat structurally similar to thyroid hormones. The theory is that using triclosan would cause the body to shut down its thyroid hormone production, causing “altered hormone regulation.” If you’re a North American bullfrog, triclosan may be a problem. This study showed that triclosan altered thryroid hormone receptor expression in premetamorphic tadpoles. Off of the lilypad, when people used .3% triclosan toothpaste for 4 years, researchers did find a significant decrease in the free thyroxine levels at the end of five years … in the control subjects who weren’t using the triclosan. In other words, using triclosan was associated with protected thyroxine levels and hormone regulation, not altered hormone regulation. ...

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