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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. 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.

Who Should Sign Death Certificates?

I happened to read an article in the Columbus (Ohio) Dispatch where Ohio coroners are complaining because some doctors, including emergency physicians, are refusing to sign death certificates listing a patient’s cause of death. The coroners are concerned because they are being “burdened” with hundreds of extra cases every year that they must handle. And if other doctors don’t sign off on the cause of death, sometimes it takes two months for them to examine records, wait for test results, and make a final ruling on a patient’s death. The treating physicians reportedly use the excuses that they haven’t seen the patients in several months or they weren’t there when the person died. Some emergency physicians expressed concern about liability if the wrong cause of death was listed. The coroners used the article to try to add a guilt trip on doctors who won’t sign a death certificate by stating that the reluctant doctors aren’t inconveniencing the coroner, they’re inconveniencing a family. Baloney. If, according to the article, it takes coroners sometimes TWO MONTHS to determine a cause of death, then how can coroners reasonably expect other physicians to determine the cause of death on the spot? How can an emergency physician determine the cause of a patient’s death just by performing CPR on a patient for 20-30 minutes? As far as death certificates apply to emergency medicine, if a patient comes in and has a heart attack or has a bullet wound through their chest then the cause of death is rather clear and the death certificates shouldn’t be a problem for the coroners to complete. If the cause of death isn’t so clear, then why would the coroners want to rush the completion of the death certificate? Either way you argue the point, it doesn’t make sense. If the amount of time required to complete a death certificate is marginal, then it isn’t as much of a burden as the coroners are making it out to be. If the amount of time required to complete a death certificate is substantial, then is the time spent performing non-patient care tasks really the best use of an emergency physician’s limited time? In addition, improperly completed death certificates are a problem. In a recent article in American Medical News, one Pennsylvania coroner was quoted as saying that many physicians “don’t realize that what they put down has some real, long-term ramifications.” The article also notes that “filling out certificates inaccurately can have widespread consequences,” although in the latter case, the speaker was referring to underreporting of some diseases to federal agencies. Another vignette in the article noted how a murderer almost went free because the cause of a patient’s death was misclassified by a treating physician. I am aware of another well-publicized case in which a personal friend of mine was involved in a medical malpractice action where a coroner determined that a patient’s cause of death was “murder” without knowing all the facts of the case. Later, the coroner was involved in litigation over that determination and ultimately resigned her position due to this and other similar errors. Requiring that people other than coroners sign death certificates is just another example of medical mission creep and it needs to stop. It is the coroner’s job to determine the cause of a person’s death. Stop pushing that job off on other people.

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Healthcare Update — 02-27-2013

Knowledgeable and honest. Yeah, that’s me. Study shows that doctors wearing white coats were most likely to be judged by patients as being the “best” physicians. Doctors wearing scrubs were also more likely to be highly rated. Of course my widespread appeal could also come from my stunning good looks or my debonaire personality … Interesting dilemma. A patient in Washington DC called an ambulance at 1:26 AM when he was having trouble breathing. Just so happens that it was New Years Eve and about 25% of the entire DC firefighting force had called off sick that day. An ambulance arrived 30 minutes later and the patient arrived at the hospital exactly one hour after the initial call for help. Unfortunately, the patient’s condition was poor and he later died. There is now a news article about how the family thinks the $780 bill for the ambulance is “appalling and hurtful.” A petition was posted on Change.org to get the DC Fire and EMS Department to drop the bill and 166,000 people have signed it, many stating that the family should sue the Department for damages. Yet the bill went to the patient’s insurance company and a copy of the bill was sent to the patient’s family – clearly stating that insurance was being billed, so the family isn’t paying for the transport. Should we not pay for less than desired outcomes? If so, should the lack of payment extend to all aspects of payments? Job performance? Government benefits? Heads at the Joint Commission are about to explode. Hand sanitizer which increases patient safety by preventing the spread of germs is allegedly to blame for burns to a cancer patient’s body after static electricity supposedly ignited the alcohol in the sanitizer and set the girl’s shirt on fire. Joint Commission news release: “Hand sanitizer is dangerous. No, it’s good. No, it’s dangerous. No it’s good. Well it’s sometimes dangerous and usually good and if any of your patients are injured by it, you’re going to have to come up with an action plan to show us why we shouldn’t decredential you for using it … or not using it. Now buy our new manual on hand sanitizer usage for $149.95 or we’ll do a surprise inspection on you.” One doctor is keeping his office open late to help care for people who would otherwise have to go to the emergency department. Unfortunately, not many patients are utilizing the convenience. But emergency departments in the area are experiencing growing patient volumes. Wonder why the disconnect? Johns Hopkins obstetrician/gynecologist commits suicide after being investigated for taking pictures and videotaping patients without their knowledge. Good news for Australian rock band lead singer Jay Whalley. The brain tumor that was causing his seizures wasn’t a brain tumor after all. Bad news: The lesion noted on CT for the past 4 years was a tapeworm egg … which has now been removed. Doctors at Boston hospital perform another face transplant – this one to replace the disfigurement of a Vermont woman whose ex-husband beat her with a baseball bat and then doused her body with lye. Kudos to the docs. Fascinating work. Doctors and hospital sued for allegedly negligently performing a C-section. While getting the baby out of his mother’s uterus, the doctors accidentally cut the side of the child’s face, causing a half-inch laceration – which was repaired with a few stitches. In Cook County, a perennial “judicial hellhole” contender, that horrible mistake could result in a multimillion dollar judgment. Go ahead, Matt. Defend this one. Chicago’s safety net for dental care is “in ...

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Dear Diary

I hate the movie Pitch Perfect. Actually I like the movie itself, but my kids won’t stop singing the frigging songs. I have heard the songs from that movie in my sleep for months now. The latest thing that my kids have taken to doing is re-enacting the “cup” scene where Anna Kendrick sings You’re Gonna Miss Me When I’m Gone using a cup. Before school in the morning, “you’re gonna miss me when I’m gone.” At night after dinner, it’s a chorus of “you’re gonna miss me when I’m gone.” Without a doubt I am NOT going to miss that damn song when it’s gone. I can’t take it any more. Ditto for Don’t You Forget About Me. My head hurts just thinking about the words. When I try to go to sleep, then it’s the dogs’ turn. About half of the nights of the week our boxer snores … loudly. Most of the time Mrs. WhiteCoat will call her name and wake her up to stop the snoring. Sometimes, Mrs. WhiteCoat has to throw a slipper at her to wake her up. When that doesn’t work, she’s actually had to tip over the bed a couple of times to get the dog to wake up. Even that didn’t work last night. After being dumped out of bed, the dog woke up, climbed back into bed, and promptly started snoring again. By that time, I was awake and I was tired. So I sat up in bed and yelled like a dog … I barked at the top of my lungs for about five seconds. I think it roughly translated into “wake up and be quiet or I’m going to tie your ears in knots.” Our older dog sat bolt upright in his bed and was looking at me with his head cocked to the side. The boxer was doing a John Belushi imitation (forward to 0:30) spinning back and forth trying to see where the attack was coming from. One of the girls let out a scream from down the hall. I laid back down and then I couldn’t sleep because I was giggling to myself. But the snoring stopped. Once Mrs. WhiteCoat went to sleep, she had bizarre dreams. In one dream she was trying to get into our oldest daughter’s room, but she couldn’t get the door open. So she broke the door in. It was freezing in the room. Our daughter was sitting on the bed and she could see her breath. “Come on, let’s go,” Mrs. WhiteCoat said. “I can’t move,” our daughter replied. So Mrs. WhiteCoat ran into the room and grabbed her, then headed for the door. The door closed and she opened it. While doing so, she bumped something behind her. She turned around. It was her carrying a laundry basket. Her mirror image dropped the laundry basket, pointed at our daughter, and said … “check her potassium level.” Then she woke up. And no, we didn’t check her potassium level. What are we going to put for the reason … vision in a whacked out dream told me to? Almost back to normal after surgery. There’s still a bulge there and yes, it is the hernia. Just some postoperative swelling. Have to wait another week before I get back into normal activity. It’s strange not feeling the area pressing up against my pant leg like it used to. And after about six days I no longer feel like I have a weight tied to one of my “boys” … if you know what I mean. Still a little sore walking ...

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Healthcare Update 02-18-2013

Some hospital CEOs just don’t like being questioned. When one hospital chief of staff led some other physicians in questioning the manner in which a hospital was being run, hospital CEO Bruce Mogel allegedly had black gloves and a gun planted in the doctor’s car. Then someone called 911 and reported that someone was driving down the street waving a firearm. The doctor was arrested in the hospital parking lot and was strip searched at the jail. The doctor sued. During depositions, a witness alleged that the CEO claimed “People do not know how powerful I am.” Now a jury has found the hospital liable for $5.2 million. It appears that former CEO Bruce Mogel got away scot-free … and is now a “consultant” at the Nelson Financial Group in Arizona. As a follow up to the article about wait times in upstate New York emergency departments, the CEO of one hospital provides a great response … and reiterates that health care insurance doesn’t equal health care access. “With a severe primary care shortage and some practices without after hours and/or weekend care, people are forced to seek care that is available … [j]ust around the corner, millions of Americans are about to have health coverage. Where will they seek care if we have not expanded access to primary care?  In the emergency room.” Government regulations never seem to get less onerous, do they? HIPAA regulations change again. Now doctors can be held liable if their business associates cause patient privacy breaches, penalties increase, and privacy notices have to be modified. For some reason, I seem to read about events like this on a regular basis. Another car crashes into hospital emergency department. This schmoe wasn’t seeking medical care, he was intoxicated and trying to get away from police. What would happen if Press Ganey ratings were superimposed on the Wong-Baker pain scale (i.e. the “smiley faces”)? GruntDoc shows you. There are 313 million people in this country. In 2008, there were 110 million cases of sexually transmitted diseases. According to census data from 2010 (.pdf file), about 60 million people are under age 14 and about 40 million people are over age 65 – both groups being lower risk for contracting an STD. That leaves 213 million people to harbor 110 million cases of STDs. To be fair, the 110 million number doesn’t separate out people who have more than one STD, so it doesn’t necessarily mean that about half the country has STDs. Even more scary, the article states that people 15-24 accounted for half of all sexually transmitted infections. That’s 55 million STDs when census data for 2010 shows that there are only 44 million people in that age demographic. Those aren’t very good odds. Ummm. You know those little spinning blades that chop things up in the blender? Yeah. They’re … sharp. When Consumer Reports’ camera man cuts his finger on a blender blade, the magazine does a little research and discovers that blender injuries have tripled in the past decade and are responsible for more than 7000 ED visits per year. More than 30 states have decided not to create Obamacare health insurance exchanges, instead opting to let the federal government do it for them. The Heritage Foundation has a brief discussion on some of the issues involved in the decision. Wacky court verdicts Aussie style. Court awards liver cancer patient $350,000 because doctor failed to refer patient to a weight loss clinic. The patient was 300 pounds and 5 feet tall. The court ruled that the patient’s terminal liver cancer was caused by the ...

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The Last Patient of a Long Night Shift

By Birdstrike M.D.   My first night shift in a stretch of 7 was almost over.  It was 6:15 a.m. and I had to keep moving otherwise the minute I would stop, my eyelids would drop like two ton shades and I’d fall asleep.  That never makes for a good drive home after a night shift. “Got time to see one more?” asked Jenny the nurse. “Do I have choice?  The door-to-doctor time storm-troopers would have it no other way,” I grunted back, eye lids drifting closed. “Febrile seizure,” it said. Good, this should be quick and easy, I think to myself.  We’ll give some Tylenol, reassess in 30 minutes and this baby will be happy, smiling and bouncing off the walls.  That way I can get out of here at 7 a.m. and be home in bed with my eye blinders on drifting towards sweet REM sleep at 7:20 a.m.  My sanity depends on it.  15 feet away, I head towards the room.  Looking into room 4, I expect to see the usual post-febrile seizure toddler, sitting up in bed, recovered, awake and well appearing.  First I see the child’s mother, well put together, attractive, smiling and relaxed.  I cross the threshold to the room, look down on the hospital stretcher and I see a child, about 1-year-old, still seizing.  Still seizing?  I think to myself.  This isn’t right. “Jenny, get in here!  We’ve got a seizing baby,” I say.  I look down at the child, who is pale, head turned to the right, with the left arm twitching violently.  “Call respiratory!  Jenny, you get the IV, I’m going to start bagging.  Someone get the Broselow tape and some Ativan.  Let’s stop this seizure.  Get some diastat, too.  We may need it.  As I bag the child, Jenny quickly gets an IV in.  We give a dose of Ativan and the baby stops seizing quickly.  The O2 sat is 97%, the baby is breathing spontaneously and I stop bagging.  I put an O2 mask on the baby.  I feel the brachial and femoral pulses.  They are bounding. Considering the baby has normal vitals, I turn to Mom hoping to get some history while hoping the baby will quickly awaken from the post-ictal slumber.  “Mom, hi, I’m Doctor Bird, tell me what happened please.” She looks at me and smiles.  Her lips spread apart and reveal a soul-sucking brown smile.  Why is she smiling?  Her baby just got done seizing?  Why isn’t she panicked?  I look towards Jenny the nurse whose face is beet red and stressed like mine, after a 12 hour night.  I shoot a glance at the clock and it’s well after shift change now.  I’m fried.  I haven’t slept in over 24 hours.  I look back at Mom and I realize she’s the calmest one in the room.  There’s something really, really wrong here.  In the corner of the room is a man sitting on a chair that I hadn’t noticed before.  He’s smiling.  I look at him.  “Hey doc!  How’s it goin’?  Havin’ a good night?” he asks with a smile and a laugh as he slaps his knee.  Having a good night?  I’m having a horrible night, I think to myself, and I’ve got a seizing baby on the stretcher in front of me.  It doesn’t seem to be cramping his style too much, however.  I feel the energy drain right out of my chest.  At that moment I know exactly what the diagnosis is, and I feel like I might puke my guts out. “Charge nurse?  Please escort them to the family consult room.  Thank you.   Suzy, call the chopper, now.  Jenny, let’s get ...

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It Didn’t Feel Like A “Win”

By Birdstrike M.D.   My kid and I are outside in the front yard blowing bubbles, enjoying the blue skies and 70 degree weather when she says, “Cool Daddy! Look, there’s a police car coming down the street. Oh, cool! I think he’s coming to see us!” Uh, oh, I think to myself. Despite my kid’s excitement, I know that rarely does anything good come delivered by a policeman. My wife is inside, my one kid is with me and my other is inside, so they’re not coming to give me some tragic news. Or are they? My parents….my siblings….is everyone okay? Why is a sheriff pulling into my driveway? I exhale for a minute. Maybe it’s Jim, the officer that lives in the neighborhood, I think to myself. He’s probably just stopping by to chat or say, “Hi.” As the car rolls closer, squinting to look beyond the window glare I see that it’s not Jim. It’s an officer I’ve never seen before. Clearly none of us has done anything to get arrested…. “Daddy! I wanna go see inside the police car! Daddy, will he give us a ride? Ooh, ooh, can I see his gun? Cool!” says my kid, jumping up and down with excitement. “Let’s see what he wants,” I answer. The driver door opens. A huge officer gets out, in grey uniform, bulletproof vest bulging underneath, with black wrap-around sunglasses, and a toothpick in his mouth. “Are you Dr. Bird?” he asks, as serious as a heart attack. “Yes, sir,” I answer. “I got a present for ya,” he says, as he pulls a thick rolled up stack of paper from under his arm and hands it to me.  “Here’s your subpoena,” he says. “My what?” I stammer. “What’s this all about?” “You’re getting….” he starts before, “Daddy! Daddy! I wanna ride in the police car. I wanna see the lights go on! Yay!” says my little one. “…sued,” I finish the sentence for him. “Yes, sir. You and every other doctor in this county it seems like. I’ve got about a dozen more to go serve. These lawyers are unbelievable. (laugh) I happen to know this one will sue you for breathin’ and win, too. You know, the one on the back of the yellow pages? You ever run into any trouble, though, you call him. Trust me, he got me out of a jam one time,” he says with another grunt-laugh. “Wow. Thanks for that wonderful advice. You’ve really brightened my day,” I snark back at this guy, who apparently thinks it’s hilarious to be part-time process server and part-time comedian. “Oh, don’t take it personally. It’s just business,” he says chuckling, as he spits out the same old lie and cliché I’ve heard a thousand times from doctors who’ve been sued. “That’s great. Thanks. Anything else I can do for you today, officer?” I ask, dejected. “Oh, yeah, I’m gonna have to give you a ticket for parking your car on the street overnight….Just kidding!” he says, and give’s a snort-laugh. This guy’s unbelievable, I think to myself as I turn to walk away. “Don’t worry, Doc. You’ll win that case. That lawyer will sue a dead dog if he could get it to settle for a bone and a biscuit,” he says. “Uh, thanks for your…uh, support,” I say, shaking my head in disbelief. Yep, it happened. After about 30,000 lawsuit-free patient encounters I finally got hit with a lawsuit. I guess 29,999 out of 30,000 isn’t bad, I think to myself. What’s that, 99.99% accurate? Well, it’s still not perfect; still not ...

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Healthcare Update — 02-11-2013

Patients gone wild. Also, a perfect example of why doctors shouldn’t play security guard. Iowa man attempts to leave emergency department, doctor doesn’t allow him to do so. Patient then slams doctor against wall and puts doctor into a choke hold before being pulled off and restrained. Who gets paid to study this stuff? “Researchers” find that number of ED visits for pubic hair grooming injuries is on the rise. I had a couple of snarky comments, but I’ll have to leave those to you all. Possible hope in battling drug-resistant superbugs? Scientists discover how to manipulate genes in bacteria to prevent bacteria from effectively eliminating waste. Waste then builds up and makes the bacteria more susceptible to antibiotics. Cook County, IL pays $20 million settlement to family of child who was “overly sedated” at county hospital then suffered heart attack and stopped breathing when left alone in recovery room after outpatient testicle surgery. Can you imagine working for more than 10% of your career with a lawsuit hanging over your head? If not, don’t become a doctor. Study in Health Affairs shows that the average physician spends more than 50 months of his or her career with an open malpractice claim. Neurosurgeons spend 27% of their careers fighting malpractice suits. Emergency physicians spend 12.8% of their careers with a malpractice claim. Dr. Ben Carson comes up with some good ideas for changing health care. A health savings account that can be passed on to future generations? Not bad. Not bad at all. Purdue University typhoid fever scare after cafeteria worker travels internationally then returns home and goes back to work. Symptoms of typhoid fever, caused by salmonella typhi, include a high fever (obviously), rash, and profuse diarrhea. Remember Typhoid Mary? Now it’s the Typhoid Boilermaker. 17 year old girl left blind, brain damaged, and paralyzed after smoking synthetic marijuana and suffering several strokes. All about the RUC and how its secretive meetings determine how much you pay for health care … and indirectly determine whether health care will be available to you in the future. Changes to the UN-Affordable Care Act make it more likely that your employer won’t provide you with health insurance. But remember … “If you’re one of the more than 250 million Americans who already have health insurance, you will keep your health insurance. This law will only make it more secure and more affordable.” More fallout from the UN-Affordable Care Act. New food labeling rules imposed in the law expected to cost grocery stores more than $1 billion per year. Grocery stores will have to provide labels on unpackaged goods such as items in salad bars. If grocers get the labeling wrong, their counsel notes that it is a federal crime subjecting the grocers to … jail time. Put down that assault crouton and step away from the salad bar, sir. Maybe they should just throw everyone in jail and get it over with. How the UN-Affordable Care Act may affect corporations – lots of outsourcing and less employment. All they need to do is create a billion dollar health care law and things like this wouldn’t happen. British hospitals serving lasagna to patients, DNA testing showed that the meat was mostly from horses, not cows. School kids got the same meals. And if that wasn’t bad enough, now some of the horse meat may actually be donkey meat. UK encourages citizens to purchase additional insurance to help pay for health care as they get older. Even though it takes a large proportion of your earnings in taxes throughout your life, your government can’t ...

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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 ...

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