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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.

Memorable Patients

Geyser 2

In my medical career, there have been a handful of patients that I remember well. Like frames on a storyboard, when I think back upon the tens of thousands of patients I have treated, these patients always seem to come to mind. Perhaps as a precursor of things to come, I even wrote stories about some of them early in my career when I saw them. I remember the first time that I drew blood on an elderly patient and how it seemed like her room was a prison cell. I’m sure she passed away a long time ago, but I can still remember looking into her eyes and wondering what this poor woman had been through in her life. I remember one of the first surgeries that I was asked to scrub in on during my Ob/Gyn rotation. They called it a “TOP”. I was excited to be a part of it. Then I learned that “TOP” stood for “Termination of Pregnancy.” I remember feeling uneasy as the resident showed me how to use the currette. I remember almost passing out when I looked through the speculum and saw a tiny white hand laying across the red surface of the patient’s cervix. I remember almost vomiting as a resident as a nurse told me that an intoxicated patient with dizziness just needed to “sleep it off” … right before he vomited a liter of blood all over her and over the curtain a couple of feet behind her. And of course there was the lollipop lady. I wrote a post about her already. Recently another patient was added to the storyboard of my medical career. I’m not sure if there was anything so memorable about her, but perhaps it was her blase demeanor in the face of a rather messy problem. Well … you can decide. The patient was in her mid- to late-60s, was well spoken, pleasant, and well-kempt. She had changed into a gown and her clothes lay neatly folded on the chair across the room. Her problem was a regulation of her bowels. First, she had diarrhea for a couple of days. She took some Imodium and Pepto Bismol and the diarrhea stopped. But then she had no bowel movement for two days. That was to be expected since after diarrhea stops it often takes the body a day or two to create more stool. The patient became concerned after having no bowel movement on the second day and she took a laxative, thinking that she may have a bowel obstruction. Then she had black colored diarrhea. Her stool was hemoccult negative, meaning the black color was likely from the bismuth in the Pepto Bismol. Bismuth combines with small amounts of sulfur in your GI tract and can turn your tongue and your stool black. Examining her closer showed that there was dried black crust all of the way down the inside of both her legs. She had passed enough diarrhea that her buttocks had become inflamed and it hurt when she sat down, so she preferred to lay on her side. She got a liter of fluid, we got a CBC, chemistries, and a stool sample just to make sure there wasn’t an infectious etiology for her symptoms and that she didn’t have a metabolic acidosis. Everything was normal. Then the strangeness began. I went back into the room to see how the patient was feeling. I could hear the lid on the infectious waste container slamming shut as I entered the room. Then I got hit head-on by a foul smell. I pulled the curtain ...

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Healthcare Update 11-04-2013

HC Update 9

See more medical news from around the web on my other blog at EP Monthly.com Like a Nazi article touting the benefits of gas chambers. Press Ganey CMO Thomas Lee writes article about current “surge” in “patient experience” published in Health Affairs. Dr. Lee’s definition of “professionalism” that he and his organization apparently expect us to latch onto includes willingness of physicians to work together to “meet[] patients’ needs,” not wasting resources, and being very concerned about data on your performance – even if that data is statistically insignificant and wholly inappropriate to use. So if we don’t “meet a patient’s needs” for large doses of narcotics and if we perform testing that we believe is clinically appropriate but which is then retrospectively deemed to be a “waste of resources” and then we don’t bow down to Press Ganey’s little red, yellow, and green boxes, then according to Dr. Lee, we must now be labeled as “unprofessional.” Another out of touch “physician” who is writing surreptitious articles for his employer. How low will Press Ganey go to make a buck? Meh. Just a flesh wound … or maybe not. Chinese man walks into emergency department with fruit knife sticking out of his head. Occurred when some kind of a “game” got out of hand. Knife actually penetrated his skull and required three hours of surgery to repair. Then the doctors sent him home with the knife. I can just hear him when he gets home and starts playing the “game” again: THIS time I go first! The White House has a brigade of Twitter attack drones just waiting to use your tax dollars for their salaries while they blast anyone who portrays the government and/or the Unaffordable Insurance Act in an unflattering light … for example an elderly survivor of metastatic gallbladder cancer who is now unable to keep her insurance plan because of Obamacare regulations. Some commenters called White House staffer Dan Pfeiffer (@pfeiffer44) a “douchebag” for attacking the patient. I think that’s being degrading to women’s hygiene products. Is that ACEP newsbyte about emergency medicine accounting for only 2% of all healthcare spending really true? Politifact says that it is … mostly. Politifact did cite a 2013 study showing that the cost of emergency care was between 5% and 10% of the total amount of healthcare spending. “Zero tolerance” in some UK hospitals after multiple “high profile” attacks on emergency department staff. Consultants note that emergency department staff deal with violence on a daily basis, yet the only measures they take to curb the violence is to make sure cameras are in place so they can catch the perpetrators after the act. When hospitals refuse to provide adequate security for their employees and are aware of the high potential for violence, perhaps the hospital administrators should be civilly and criminally liable for any injuries sustained by their employees. Michigan House Bill No 4354 (.pdf) would make it much more difficult to sue physicians or hospitals for EMTALA-related care. Requires proof by “BY CLEAR AND CONVINCING EVIDENCE THAT THE LICENSED HEALTH CARE PROFESSIONAL’S ACTIONS CONSTITUTED GROSS NEGLIGENCE.” This is a very high legal hurdle. Article notes that “the liability in such medical situations has many specialists declining to be on call.” A study performed by the Michigan College of Emergency Physicians showed that states such as Georgia and Texas that enacted similar reforms had an increase in physicians. Apparently the concept that we can’t “sue our way to better health care” is beginning to take hold. Notice how all the attorneys in the comment section argue against the legislation. Head of Veterans Affairs writes a letter to US Representative ...

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Otitis Externa and the Ear Wick

Ear Wick Package Front

This is the first in a series of posts to explain some common medical problems to patients in a hopefully easy-to-understand manner. Otitis Externa Otitis externa (or “swimmer’s ear”) is an inflammation of the outer portion of the ear canal. It is different from a middle ear infection (“otitis media” or the typical “ear infection” that typically afflicts children) because otitis externa affects only the ear canal (see the red area in the picture below) while otitis media is a collection of pus behind the eardrum (see the yellow area in the picture below) that does not affect the ear canal. Patients with otitis externa often have significant pain in the outer ear and may have swelling and/or drainage from their ear canal. One of the easiest ways to tell whether a patient has swimmer’s ear is the “tragal tug” — pulling outward on the cartilage of the ear (like your mother used to do when she was mad at you). Pulling on the ear will cause traction on the skin within the ear canal. When the skin inside of the ear canal is inflamed and is stretched, it will hurt. Therefore, patients with swimmer’s ear will usually have significant pain when their ears are pulled. The pain from inner ear infections usually doesn’t get much worse with the tragal tug — unless otitis externa is also present. Mild cases of otitis externa can sometimes be treated by putting Burow’s Solution into the ear canal a few times a day. When a patient is diagnosed with otitis externa, drops containing antibiotics and steroids are often prescribed. It is a good idea to check the ear drum for signs of perforation before putting medications into the ear. If some medications get into the inner ear (the yellow area above), they can cause dizziness, ringing in the ears or even hearing loss. For example, Cortisporin Otic and other aminoglycosides have the potential to damage the vestibula with prolonged use. Quinolone/steroid combinations are less likely to cause such damage. The Ear Wick If you put drops into the ear canal and then stand upright, then the drops all collect on the bottom of the ear canal. Eventually, they either get absorbed or they drain out of the ear canal. Additionally, if the ear canal is swollen shut or nearly swollen shut, the medications may not get to the affected areas in the ear. An ear wick solves both problems. An ear wick is a piece of sponge (or sometimes a piece of cotton) that is inserted into the ear canal. Topical medications are then put onto the ear wick and then capillary action pulls the medication further into the ear canal. The wick helps to keep the medications in the ear and helps to hold the medication along all surfaces of the ear canal. As the ear heals, the wick usually falls out on its own. If not, a medical professional can easily remove it.    

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The “Unnecessary” Test

Head Child Porcelain

Here’s a real case submitted by a reader. A two year old child is brought into the department by her father, her mother, her grandmother, and her greatgrandmother. All were very concerned. The child was walking on a curb using her dad’s hand for support when she lost her balance and fell. Her dad didn’t catch her quickly enough and the child struck the side of her head. The mother said she saw the child’s head “bounce off the concrete”. Both mother and child cried immediately after the accident. After about 10 minutes, they put the child into the car. She went to sleep immediately. The mother tried shaking her leg, but she wouldn’t wake up. The father then stopped the car and they took her from the car seat and shook her. She still didn’t wake up. They called grandmother who called great grandmother. All agreed to meet at the emergency department. When she got to the emergency department, she was alert. In fact, she was running around the room opening drawers and pressing buttons. Both parents had to restrain her just so she could be examined. Even then, she wouldn’t sit still. A thorough exam of her head showed absolutely no signs of injury. She did say “ouch” when the back of her head was palpated, though. Normal pupils. Normal TMs. Normal neck. No Battle Sign. No other evidence of inury. No vomiting. In other words, she met all of the criteria for a “low-risk” head injury (.pdf) except for the parents’ history of this prolonged unresponsive state. Three generations of family members want a CT scan of the brain. The explanation of injury doesn’t match the physical findings and you believe in your heart that the parent’s story of a 15 minute episode of unresponsiveness is inaccurate. You also know that there’s no way that the child will sit still for a CT scan. That means that you’ll have to do conscious sedation (including all the extra paperwork required by the Joint Commission) and observe the child for a couple of hours after the CT has been performed. If you do the test and it’s normal, then you will be accused of performing defensive medicine, the nurses will be pissed at you for the rest of the shift, your productivity will tank, you’ll get an e-mail from your department chair about all the complaints from patients for the long waits, you’ll get bad Press Ganey scores from the upset patients, and you may get a letter from hospital administration for “overutilization” of resources. If you don’t do the test, the family will be upset with you, will accuse you of providing poor medical care, and will give you bad Press Ganey scores (and you’re on the CEOs hit list for the two bad scores you had last quarter). Oh, and if you don’t do the test and the kid has a bleed, you’ll be sued, the chart will show that everyone in the family thought the CT should be done and you were just too dumb to perform it, and the State Medical Board will likely bring a licensure action against you … which could result in you not being able to practice medicine any longer. What do you do? ———————– 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 not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me. I’m making full blog posts available to ...

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The Bloody Knife

Bloody Knife

Patients seeking refills for chronic pain prescriptions are finding that those requests are being rejected more and more often by emergency departments. Due to the increasing incidence of drug diversion and doctor shopping, many hospitals are developing policies that limit or even prohibit prescription of controlled substances for chronic medical problems. But every time that people build a better mousetrap, Mother Nature builds a better mouse. Patients know that they won’t get prescriptions for chronic pain, so they often come in complaining of acute injuries. Lots of falls down stairs with acute back injuries, lots of twisted ankles, some neck spasms after non-reported car accidents. So not only do the patients get their medications, they often get additional x-rays … which drives up the cost of their medical care. One regular patient was reportedly pretty creative with her acute injury. She came in with significant pain in her thigh after suffering a stab wound. In fact, when she rolled in the doors on the ambulance stretcher, she still had a paring knife sticking out of her leg. Police weren’t called though. The injury was self-inflicted. Turns out that the patient was using a paring knife to make herself a baloney sandwich. While she was standing in the kitchen spreading mayonnaise on the bread, her leg kept twitching. In fact, the twitching got so bad that she had trouble standing upright. So in the spur of the moment, she stabbed herself in the leg to make her leg stop twitching. It worked. Of course, now her pain was “at least a twelve” on a 1-10 scale. And her allergy list included all NSAIDS, codeine, and Tramadol. She got cleansed, sewn up, and discharged with Tylenol – fortunately she wasn’t allergic to that. She also got to follow up with the neurologist to address the case of the incessantly twitching leg. The knife got confiscated and thrown into a sharps bin. And everyone kept wondering what she was going to do with her baloney after that incident … ———————– 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 not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me. By the way, I’m making full blog posts available to the RSS readers and newsfeeds to make them easier for subscribers to read. Want to help support this blog? If you’re looking to purchase medical supplies online, Pharmapacks.com has Home Medical Supplies for Less. They accept PayPal payments and have free shipping on orders over $69. This blog gets a small percentage of each sale as a commission at no added cost to the customer.

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Healthcare Update 10-28-2013

HC Update 17

Finally … Now you can catch updates both here and on my other blog at EP Monthly.com If you like your insurance, you can keep your insurance … that is until the insurance company cancels the policy because it doesn’t meet the Obamacare requirements. Florida Blue is canceling about 80% of its individual policies and Blue shield of California is canceling 60% of its individual policies. Most of those cancellations will see their insurance premiums rise in new policies – if they can afford to purchase them. Now there are reports that POTUS knew that whole “keep your insurance” statement was untrue from the start. How sad. Want to know how much you’re going to pay once your insurance coverage gets dropped? Don’t go to healthcare.gov. According to this article, the prices quoted on the healthcare.gov site are wildly inaccurate. One patient found that the cost for a policy was 50% more than quoted on the site. Another patient reportedly was quoted a price of $394 on the government site when the actual cost of the policy was $634. If private companies did this, it would be considered consumer fraud. How export limitations and drug shortages affect executions. Interesting story. Sodium thiopental supply has dried up. Then prison officials began to look at using propofol for lethal injections. That was the drug that reportedly killed Michael Jackson. However, most propofol is made and exported by a German company which is subject to EU regulations limiting export of drugs for use in capital punishment. If misused in the US, the EU could deny further exports of the drug. According to the article, US regulations “make propofol difficult to manufacture in the US.” Now prisons are looking at using midazolam (Versed) as a substitute in lethal injections. The drug is made in the US, but it isn’t tested for executions. During one lethal injection, the prisoner was reportedly awake and blinking during his execution. Do we go back to firing squads? Speaking about Michael Jackson’s death … Conrad Murray was released from jail today after serving half of his four year sentence. I was going to link to the story on ABCnews.com, but they have an annoying autostart video when you click on the story. So F them. New research shows promise for hair growth. Researchers grow human hair papilla on a culture medium, then inject them into hairless areas. New hair follicles form. They know this because they were able to get hair to grow onto grafts of human foreskin. No, men aren’t going to have to shave their woo hoos … foreskin is hairless and they wanted to make sure that the procedure grew new hair follicles instead of affecting existing hair follicles. University of Michigan study shows that 77% of parents want to be able to e-mail doctors about children’s health care problems. However, half of the parents think that they shouldn’t have to pay for e-mail medical consults. In other words, the parents want doctors to spend hundreds of thousands of dollars on a medical education, pay tens of thousands of dollars each year in licensing and insurance fees and then provide services at no cost. Sounds like a sustainable business plan to me. Study in the American Journal of Emergency Medicine shows that obese patients may not receive proper medication dose when using EpiPens. The needle length on the EpiPen is only 1.6 cm while the amount of fatty tissue in obese patient thighs was much more than that. About a third of patients were failure risks. Women were 6.4 times as likely to receive inadequate medication doses ...

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