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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.


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.

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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.

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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. ...

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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 ...

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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 ...

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Comic Relief

Another cartoon courtesy of Mednificent Comics. The answer to the question at the end … “absolutely”

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Healthcare Update 01-21-2013

Amount of medical malpractice in the military is “shockingly underreported”. To add insult to injury, the Supreme Court continues to deny injured patients the ability to sue the government for damages from medical malpractice in military hospitals under the Feres Doctrine. Oh, and do you think that you’ll be able to compare hospital “quality” between military hospitals and other hospitals using the federal government’s web site? Think again. No data available for military hospitals. Walter Reed Army Medical Center doesn’t exist in Washington DC when you’re trying to see the quality of care that is being provided. Makes you wonder what they’re trying to hide. Medicare planning to penalize 2,217 hospitals for excess readmissions. Since there are only 5,700 hospitals in the entire country, wouldn’t it just be easier and less costly to flip a coin and penalize hospitals based on that? Seems to work with Press Ganey. Hat tip to @MDAware Job security. Star of MTV’s new series “Buckwild” discusses how he is on first-name basis with his local emergency department due to his antics – which include the backhoe rollercoaster and rolling in a tire down a hill. German surgeons accused of leaving up to 16 foreign bodies in a patient’s abdomen after prostate surgery, including needles, compresses and surgical strips. Hospital denies accusations, stating that the “equipment wasn’t in use at the hospital.” The thing that caught my attention was the demand for compensation – $106,000 – followed by the hospital spokeman’s statement that the amount of the demand was “unusually high” for such a case. Hat tip to Drudge Enema tamperer pleads guilty to one count of product tampering for using enemas then putting them back into the boxes and returning them to the stores. Faces up to 10 years in federal prison. Patients gone wild. Maine woman arrested after assaulting two emergency department staff members. You had to know this was coming. After news reports that energy drinks are resulting in more trips to the emergency department, brainiac Chicago Alderman Ed Burke wants to ban energy drinks. It’s for the safety of our children, you know. Next up: banning coffee. I hope this Bloomberg nanny philosophy isn’t contagious. Too much more of this stuff and we’d have to ban him. It’s for the safety of our children, you know. The neverending drip? Canadian study shows that gonorrhea cases increasingly resistant to cephalosporins, increasing possibility of untreatable sexually transmitted diseases. It appears from another article (I’m not paying for JAMA access) that the patients were subsequently cured with other antibiotics, so all hope isn’t gone quite yet. Ever wanted to learn how to wrap an ankle? Here’s a “how-to” guide by someone who says he’s wrapped more than 100,000 ankles in his career. Putting GPS tracking chips into fake pill bottles to deter pharmacy robberies. Yeah, that will work. Hulk Hogan files $50 million lawsuit against Laser Spine Institute … in Florida … for for allegedly performing hundreds of thousands of dollars in unnecessary minimally invasive surgeries. The Affordable Care Act or the Affordable “No-Care” Act? Pennsylvania’s Windber Medical Center decides to discontinue providing obstetrical services – in part because obstetricians are leaving the area and in part because of “lower reimbursements under the federal Affordable Care Act”. But remember … you can still see any doctor you want under this legislation! As long as you’re paying cash, that is. Drowsy driving kills. According to this MMWR report, 4.2% of people admit to driving drowsy in the prior 30 days and drowsy driving is implicated in 2.5% of fatal motor vehicle crashes according to the  National ...

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What’s the Diagnosis #15

An elderly patient presents with leg weakness over the prior two days. The day of presentation he also notices pain in his upper back which seems to be fairly persistent. His medical history includes diabetes and renal failure. He was dialyzed the afternoon prior to his presentation and his glucose was 264. The patient’s daughter stated that he “wasn’t acting himself.” The patient’s physical exam was fairly normal. Perhaps a little weakness in his legs, but he still moved all extremities. His current EKG (dark background) and another EKG faxed from a different hospital done six months earlier (light background) are shown below. You can click on them for larger images. What’s the diagnosis and what’s the next step? I’ll post the answer underneath the EKGs in a couple of days. . . . . . . . .         ———————— Answer:  Severe Hyperkalemia The patient’s potassium was 7.9. The history of being dialyzed the day before his presentation confounded the picture. The EKG was worrisome enough that the patient was initially labeled as an acute MI and the cath lab was activated. Then one of the docs noted that there were no P waves and that the T waves were narrow and peaked which was consistent with a picture of hyperkalemia. The dialysis center was contacted and stated that the patient only had an hour of dialysis the day before his presentation because they were having trouble with his shunt. The dialysis center contacted the patient’s doctor at another facility whose colleague faxed a copy of an old EKG to the ED. A repeat EKG done 20 minutes later showed no further changes. After receiving calcium, dextrose, insulin and albuterol, the patient’s EKG showed substantial improvement. The post-treatment EKG was performed 20 minutes after receiving the medications. Serial cardiac enzymes remained normal. Aortic dissection is known to cause ST elevations in V1 and V2, but couldn’t find a report of a patient having such findings in the absence of chest pain. . . . . . . .  

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