Home / Blogpage 20


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. 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.

Spaghetti and Impaction

Stool impactions probably aren’t what most people would consider an “emergency” … until they actually have a stool impaction. Personally, I wouldn’t wish a stool impaction on someone. In chronic constipation, more and more stool collects in the colon until size of the ball of stool is too big to pass through the opening to the outside world. The major function of the colon is to absorb water from the stool, so the longer the stool sits in the colon, the larger the amount of water that gets absorbed, and the harder the blob of stool gets. By the way – the whole water absorbing function of the colon is why it is important to keep well hydrated to maintain good bowel habits. There are a lot of ways that you can try to get rid of a stool impaction, but when the stool gets hard enough, pretty much the only way to remove the impaction is by having someone use their fingers to perform a “disimpaction.” There’s just no good way to get a big hunk of stool the consistency of clay soft enough for it to pass through the rectum. It has to be dug out. Disimpactions aren’t fun for the doctor or the patient. They’re painful and obviously messy. I’m probably more willing than most docs to perform disimpactions because I can see how much the patients are suffering. Although unpleasant, disimpactions are an easy fix to the patients’ problem. Like I said, you probably can’t appreciate how bad impactions are until you’ve been on the other side of the gloved finger. As I donned my mask, gown, and multiple layers of gloves to commence the procedure on one patient,  one of the nurses sent a nursing student in the room with me to observe. The student said that she had seen “many” disimpactions in the past, but the nurse wanted her to observe this one, so she reluctantly came in the room with me. I introduced the student to the patient, then had the patient lay on his side and pull his knees to his chest. The nursing student stood against the wall behind me. “OK, Mr. Smith, you’re going to feel some pressure. I’ll try to be as gentle as I can.” The patient muffled his moans as I began removing stool. Although the large impaction appeared relatively solid on the x-ray, the initial pieces of stool that came out were in little round globs. Then the nursing student tells the patient “Oh, you just have little balls. This shouldn’t be too bad.” I stopped for a second and cocked my head to the side. In the awkward silence that followed, the student realized what she had said and tried to correct herself. “I mean little balls in your rectum.” I looked back at her and started to chuckle. “I mean little balls of stool.” At that point, she was beet red and she excused herself from the room. “Sorry about that, Mr. Smith, she’s still learning.” “She had me worried there for a second. I thought you were going to go grabbing my nuts next.” The nursing student had taken an afternoon lunch break by the time I had removed all the “little balls.” I was hoping they were serving spaghetti with meatballs so I could ask the student if she gloved up before lunch, but no such luck. ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may ...

Read More »

Dear Diary

Well, I thought we escaped it, but we didn’t. The past week has been full of emesis, diarrhea, and disinfectant spray. Just when we think that things are on the mend, someone else in the family starts having a stomach ache. The vomiting is the worst. When it starts out, it sounds like a loud belch … until you hear the progression of the sounds. Yeah. Too much information. But on a good note, I have seen that my kids are immune to boredom. They were able to watch the same episodes of Disney sit-coms a half dozen times and still got mad when I turned off the television. I’ve cut back on my work hours a little which gives me some extra time to hang out with Mrs. WhiteCoat and the kids. Kind of fun taking a morning to walk through the mall or going to lunch and catching a matinee before the kids get home from school. In fact, I took about a 30% pay cut from previous years, but we’re happier than we were before, I get to see a lot of the kids’ events that I used to miss, and we pay a lot less in taxes. Last weekend at one of my son’s wrestling matches, I had some mom from another team call me an asshole. Probably won’t be the last time. And I wasn’t even the one instigating. Wrestling matches last 1:30 each round. There are three rounds per match. It was a team meet and my son’s team was just barely beating another team — whose parents were sitting in the bleachers right next to us. During one of the matches, their wrestler was getting beat and, while on the mat, he signaled the referee that he was hurt. The referee stops the match and the wrestler jumps off the mat and goes to get some water. Several of our parents started yelling. Wrestlers aren’t allowed to take water breaks in the middle of matches. The opposing team’s parents started yelling at us. I kept my mouth shut. Mom from their team: “You all can just shut up!” Mom from our team: “You BETTER not be talking like that to my family.” One of our team dads yells “Your kids get water breaks? Our kids don’t get water breaks. Is that in the rules somewhere?” A loudmouth mom from the other team yells “Hey SHUT UP. He has ASTHMA.” Then I just let out a spontaneous laugh. I wasn’t laughing at the kid’s medical problem. I just thought to myself that I’ve been doing it wrong all these years. I should just be giving patients drinks of water instead of steroids and albuterol for their asthma attacks.  What a dunce I am. Loudmouth mom looks at me and yells “What are you laughing at, ASS-HOLE?” Them’s fighting words, of course. But I kept my mouth shut. I just smirked at her, held my water bottle high in the air, and took a long swig. Mmmmm. Breathing better already. The water didn’t help as their wrestler got pinned shortly after his water break ended. I had about a half dozen snarky comments that I wanted to blurt out at the mom, but I didn’t want to start a brawl in the stands. So I opted to have another long swig of water. Mmmmmm. Next week I’m having another surgery … on Valentine’s Day no less. Hopefully not a big deal. Just getting a hernia repaired. I’ve been dealing with it for a while, but now it has gotten big enough that it hurts, so ...

Read More »

Healthcare Update — 02-04-2013

Chinese man runs out of money to pay for dialysis. Government “insurance” only pays half the costs of treatment (keep that in mind, Affordable Care Act supporters). Then human ingenuity kicks in. The man builds himself a dialysis machine out of used and discarded medical equipment, mixes his own dialysis fluid, and has been dialyzing himself … and it has been keeping him alive for 13 years. Doctors hearing about his unorthodox methods warned him about the risk of serious infection and “long-term complications” because he wasn’t using sterile water to make his dialysis fluid. Something tells me that if the complications were that likely, they probably would have happened in the past 13 years. After getting outed in the media, the Chinese government then offered to provide him with assistance to pay for his treatment. He’s reluctant to take the government up on its offer. I wonder what would happen to this patient if he was in the US. Hat tip to @MedicalQuack Just call them “assault” bacteria when you describe how they kill people – our legislators and the media will jump all over that. We can’t let ourselves become complacent over drug-resistant bacteria. Interesting point … once doctors become employees, does their incentive to fill their schedule with patients decrease? Will they want to stay late in the office to see an urgent patient? Will they go on strikes and leave patients without health care? See how access to care decreases as the paradigm unfolds. With increasing numbers of antibiotic resistant organisms in hospitals, do we need to start asking whether it is safe to go to the hospital? By the way, your ZeePack is becoming less and less effective against all types of infections because bacteria see so much of it prescribed, but for lunch these resistant organisms drink ZeePack cocktails and then have Levaquin hors d’ourves … and then they laugh at the people spending money on ineffective medications. Medical device company Stryker cuts 1,170 jobs, citing the Affordable Care Act as the reason. Medical device company smith&nephew cuts 100 jobs in the US due to the Affordable Care Act. Then the IRS states that the least expensive health insurance plan available in 2016 under the Affordable Care Act will cost a family $20,000 per year. If you don’t pay up, you are forced to pay an extra tax/penalty. Maybe we need to start calling it the UNaffordable Care Act. The good news is that they won’t develop intestinal worms any time soon. The bad news is that the medication some drug dealers mix with cocaine and heroin may cause dangerously low blood counts and skin necrosis. California patient becomes upset about incontinence which occurred after prostate surgery, goes to doctor’s office and shoots him dead. Busting 5 malpractice myths? Some of the claims seem spurious to me. HT to @epmonthly 101 year old Chinese woman declared dead and then wakes up at her funeral – just as she was being put in her coffin. Now all I can think of when I hear stories like this is a YouTube video one of my co-workers once showed me. New Surviving Sepsis guidelines have been released (.pdf file). Nice summary here. Norepinephrine is the pressor of choice. Initial fluid bolus of 30ml/kg recommended. Hat tip to @kane_guthrie If you want to kill your husband, putting poison in your hoo hah and asking hubby to have a whiff probably isn’t the safest way to go about doing so. There are just too many comments that can be made to this story. More than 7,000 residents of Great ...

Read More »


One of our registration clerks thinks she’s pretty slick. We play little practical jokes on each other every once in a while. One day she’ll unplug the keyboard to my computer when I’m in a room with a patient. I’ll come out to try to enter orders and start pounding the keyboard. Another day I’ll squirt a syringe of saline onto her chair so her butt gets wet when she sits down. And on and on and on. Recently, she tried to scare me. My desk sits across the station from hers and my back is to her. She thinks I can’t see her, but I can see everything that goes on behind me by the reflection off of the x-ray computer screen. While I was looking at an old chart on the screen, I saw her get up out of her desk, put her finger up to her lips to tell everyone to be quiet, and try to sneak up behind me. She was trying to tip-toe, but I could hear her little clown sneakers squeak as she walked. When she got close enough to me, she dug her fingers into my sides and yelled. I saw it all coming. I acted like I was sleeping and I stretched my arms up in the air, yawning. [Yawwwwwwn] “Is it time for me to go home already?” “You think you’re funny, don’t you WhiteCoat? Just wait. I’ll get you yet.” When my shift was over, I decided to make a pre-emptive strike. The registration clerk sits in a little cubby hole of sorts. There’s a line of several windows – one for each registration clerk – with a ledge and two chairs in front of each one. There’s a wall right next to the window where she was sitting. The clerks can’t see around the wall from that seat, so there is a mirror across the hall that the clerks use to see if patients are coming. Due to several slow nights at work, we discovered that shadows in the waiting room created a few blind spots in the mirror. I said goodnight to everyone, got my coat on, and acted like I was leaving for the night. I waited a few minutes and watched the clerk in the mirror. Soon she settled into reading a book on her Kindle which she rests on the computer keyboard. I then pulled my hood over my face, ran up to her window, slammed one of my hands on the desk and in the best Jacob Marley voice I could muster, I yelled “Hellllp!” Then I fell over onto one of the chairs and fell on the floor. The clerk jumped out of her skin, then screamed. “Aaaaaah! Where the hell did you come from?!?! Aaaaaaahhhh Get a nurrrrrrse Get a dooooctorrrrrr!” There were a couple seconds of silence, then her little head poked through the open window over the ledge to look at me on the floor. I was laughing so hard I had trouble catching my breath. “Damn you, WhiteCoat! You just made me wet myself.” And I didn’t even need a syringe of saline to do it.

Read More »

Post Online, Get Investigated By State Medical Board

Earlier this month, a survey of state medical boards published in the Annals of Internal Medicine showed that many state medical boards were willing to investigate physicians for lack of online “professionalism.” The authors of this study created 10 vignettes regarding online physician behavior and then queried state medical boards regarding their likelihood of “investigating” physicians based upon the scenarios. Percentages of state medical boards that were “likely” or “very likely” to investigate a physicians for behaviors were as follows: Citing misleading information about clinical outcomes — 81% Using patient images without consent — 79% Misrepresenting credentials — 77% Inappropriately contacting patients — 77% Online posts depicting alcohol intoxication — 73% Violating patient confidentiality — 65% Using discriminatory speech — 60% Using derogatory speech toward patients — 46% Online posts depicting alcohol use without intoxication — 40% Providing clinical narratives without violation of confidentiality — 16% Think about the implication of some of these circumstances. It takes 4 years of college, 4 years of medical school, 2-6 years of residency, and hundreds of thousands of dollars in expenses in order to obtain a medical license. Based on this article, there is theoretically the potential for a medical board to take away 10-16 years of work because a physician makes a post about drinking alcohol or because a physician writes about a patient’s case — even without violating a patient’s confidentiality. Even if a license is not revoked, an investigation could be initiated based on vague and sometimes anonymous complaints about “discriminatory” or “derogatory” speech or citing “misleading” information. Such complaints would require that a physician retain legal counsel in order to proceed through a drawn-out investigation. The expenses involved in the investigation may not be covered by malpractice insurance. For those who have never had the experience of being “investigated” by a state medical board, the process do not have to follow the rules of court, may involve threats from investigators or pressure to immediately sign “confessions,” and it is not uncommon for investigations to quickly become witch hunts. Here are some of one lawyer’s experiences in dealing with Licensing Boards. Remember the issue with Amanda Trujillo, RN who was investigated by the Arizona State Nursing Board for informing a patient about her surgical options? That case turned into an 8 month inquiry into every complaint alleged against Amanda for the prior 3+ years at multiple hospitals in multiple states. The Nursing Board also reportedly informed her that they would further discipline her if she continued publishing their communications with her. A couple of things work in a physician’s favor if being investigated by a medical board. A medical license is usually considered “property”, which may allow a physician to pursue a due process claim if a medical board takes inappropriate actions against a physician’s license or does not follow proper procedure in pursuing those actions. This Washington Supreme Court case contains a very good discussion about the problems involved in actions taken against a physician’s license. Also, in many states, attorney’s fees are awarded for successful due process violation actions. Don’t be afraid to fight back against inappropriate state medical board claims. As Glenn Reynolds likes to say on Instapundit … punch back twice as hard.

Read More »

Healthcare Update — 01-28-2013

You can keep your doctor and your insurance … if you can afford it. Some insurance brokers expect health insurance premiums to triple in the fall prior to full implementation of Obamacare. Oh, and if you can’t afford that insurance, plan to pay a punitive tax. But don’t worry, Mississippi Gov. Phil Bryant thinks that everything is fine now. Everyone in America has health care. All they have to do is go to the emergency room. Once no one can afford private insurance due to premium hikes, then government funding cuts can affect essential hospital services – like what is happening in Australia. Should smokers and obese patients be left to their own vices? Is increasing their insurance premiums an additional 50% above regular policy premiums under Obamacare enough? How do you get chemotherapy, heart surgery, mental health treatment, and a wheelchair when you have no insurance, no home, and no money to pay for your health care? Threaten the life of the president and his family. Homeless Florida man makes habit of threatening sitting presidents when he needs a place to stay or he needs medical care … and it works. Sad that federal prisoners receive better medical care than many hardworking law-abiding citizens. Smoking decreases life expectancy by 10 years. Risk is decreased by 90% if smoking stops before age 40.  Most of the excess mortality among smokers was due to neoplastic, vascular, respiratory, and other diseases that can be caused by smoking. The probability of surviving from 25 to 79 years of age was about twice as great in those who had never smoked as in current smokers (70% vs. 38% among women and 61% vs. 26% among men). Florida medical malpractice changes? Pain pill abuse occurs because doctors don’t take drugs seriously … according to insight from an administrator at the DEA. California hospitals being overrun by patients suffering from influenza. Is this any indicator about how the hospital is being run? Kudos to Bongi for his blog being rated the best medical blog on the internet by a Forbes writer. Well-deserved! 150 year-old Long Island College Hospital in Brooklyn may close due to financial pressures. Louisiana jury awards mother $24.2 million after child undergoes heart surgery and pump malfunctions during surgery, allegedly causing cardiac arrest. Patients gone wild. Well … this time it is a patient visitor who jumped a counter to see his wife then assaulted several staff who tried to restrain him. Just wait until those horrible staff members get their Press Ganey scores. Whiplash injuries don’t benefit from active management. Lyme Disease 2.0. New Jersey woman exhibits symptoms of Lyme Disease, but tests negative. Examination of her spinal fluid shows newly-discovered organism borrelia miyamotoi instead of borrelia burgdorferi which causes Lyme Disease. I don’t believe it! Medicare planning to penalize doctors $1.3 billion per year for failing to report “quality” measures. You don’t say! Penalizing hospitals for excess 30 day readmissions has no clear “biological, clinical or therapeutic evidence base” and subjects hospitals that improve patient’s mortality (death) rates to “unjust[] penaliz[ation] under the current reimbursement system. Anyone out there who thinks that the federal penalties for 30 day readmissions are about improvement in “quality” and not about the government creating another way to take money away from hospitals is just plain naive. Curious about statistics regarding admissions and repeat visits within 30 days after hospital discharge? Out of more than 5 million patient visits studied, 18% had at least one acute care encounter within 30 days and 14.7% were readmitted. ED visits accounted for 40% of all post-discharge acute care encounters. ...

Read More »

What’s the Diagnosis #16 — Mmmmm, Eggs

This is an interesting case for a number of reasons. First, it shows how a little testing can turn into a lot of testing to “rule out” diseases in the emergency department. Second, it hopefully provides some good teaching points. Third, the comment from the attending physician gave me the giggles. That will explain the title. But you have to read through the case to understand the comment. I’m not going to discuss all the minute details of the case, only the major findings that contribute to the flow of the case. A patient got sent in from the nursing home because her gastrostomy tube was leaking blood and the nursing home was convinced that the patient was having GI bleeding. When the bandage over the patient’s G-tube was removed, it was fairly obvious that the skin about the G-tube site was the source of the blood. The skin was raw and was oozing dark red blood. Flushing the G-tube produced a little blood, but the blood cleared. The patient’s vital signs were stable except for a mildly elevated pulse. Proper skin care probably would have resolve the bleeding. Some people may have left it at that and sent the patient back to the nursing home. I drew labs and did an abdominal series. The patient was mildly anemic. Her hemoglobin was 11. There was no blood in her stool. Her BUN was mildly elevated at 24 which suggested that she was behind in her fluids but not that she was having a significant upper GI bleed. With significant GI bleeds, BUN tends to increase quite a bit when the body digests blood. The abdominal series showed that the G-tube was correctly placed and that there was no free air under the diaphragm. However, the chest x-ray showed another worrisome finding. In the bases of both lungs there was scarring and some placques that went along with the patient’s exposure to asbestos many years ago. However, the patient’s mediastinum was maybe just a lit-tle wide. There are a couple of measurements you can use to make that determination. Width > 8 cm on a PA view of the chest. Ratio of mediastinal width to chest width > 0.38. We used to say if the width of the mediastinum on the x-ray film was greater than the width of your pager, that was a problem. Now the youngsters don’t even know what a “hot light” is and some of them haven’t even heard of a pager. How wide is an iPhone these days? Anyway, if the mediastinum is wide, there are several significant life threats that need to be at least considered. Aortic aneurysm,  aortic dissection, and cancer are probably the most concerning to the emergency physicians. CT scan of the chest with contrast is one way to test for those conditions. So the patient with a minor G-tube problem was now getting a CT scan of the chest. Obviously something that many would consider an “unnecessary test” for the complaint of a GI bleed, but a rabbit hole that warrants jumping into during the workup of a markedly abnormal chest x-ray. Because the GFR was a little low, the patient got extra IV fluid before the scan to try to avoid contrast nephropathy. The CT scan of the chest comes back with a little surprise. The aorta was OK, but there was another reason for the patient’s wide mediastinum. The patient had a diagnosis of achalasia and wasn’t supposed to be eating anything. Turns out that the nursing home staff was giving her treats every now and then when the ...

Read More »

More Joys of Electronic Medical Records

Go up to your favorite emergency department staff member and ask them what they think of “twofers.” Depending on that person’s mood, chances are that you’ll get anything from a scowl to a punch in the gut in response. Two patients from the same family both needing emergent medical care at the exact same time? It still happens … car accidents, fires, maybe a stomach bug. But it can be frustrating. There’s a saying in emergency medicine that the likelihood of a true emergency is inversely proportional to the number of patients in the family registering to be seen. That being said, a “fivefer” will raise the hairs on the back of the neck of pretty much any emergency department personnel. When the complaint is that everyone in the family has a cough, three of the five family members smoke, and none of them got their flu shots … well … you get the picture. One of the frustrations with scenarios like this is the charting involved. The nurse and the doctor are literally stuck at the computer for 30 minutes each, both entering useless information about different patients over and over again – instead of taking care of other patients. The medical records won’t let you proceed without entering the information. Is there a fall risk? Is there a risk for tuberculosis? Does the patient smoke? Nurses have to enter this information even on infants to satisfy government regulations. Is there a risk of danger in the home? Is there evidence of abuse? When entering an order for IV fluid, if the patient has a sulfa allergy, doctors have to acknowledge that there is some potential interaction between saline and the patient’s allergy and describe why we would dare to give salt water to a patient with an allergy to sulfa. And on and on and on. So I tried something that sounded easy when I thought of it, but was technically quite difficult when I tried to actually do it. I tried to log the number of times I clicked on different check boxes and the number of different screens I had to navigate in order to document on and discharge/admit a patient. This is easier said than done. I never realized how quickly I am able to navigate a byzantine array of computer screens. After clicking on one button to order a medication, I found myself subconsciously moving the mouse to the area of the screen where the next “OK” button would pop up. I had to literally slow myself down to count the clicks and the screens. I’m sure I missed a few in the process. The number of data points in each aspect of a patient’s history is quite large. There are 144 data potential points to click on just for a patient’s physical exam. The screen to the right is what must be navigated for each and every patient’s history. Each line in the white fields is a data point that must potentially be either right- or left-clicked depending on whether it is positive or negative. I didn’t even bother counting up how many potential data points could be clicked upon, but it numbers in the several hundreds – depending on the presenting complaint. So I set out to log the clicks and screens. The first few times I tried, I wasn’t able to do it. Finally, when it wasn’t so busy, I made a conscious effort to stop on every screen and mark down clicks and screens. I use some basic templates, so the amount of clicking that I do is actually less ...

Read More »