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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.

The Nurse Who Denied CPR

I’m in shock about the case where a nurse refused to give CPR to 87 year old Lorraine Bayless in a California senior living facility – a housing setup akin to an apartment complex. Ms. Bayless fell unconscious in the dining room of a senior living facility. Facility members called 911. Ms. Bayless wasn’t breathing and the 911 operator recommended that the facility member perform CPR. The person at the facility would not perform CPR. It took EMTs about 7 minutes to arrive on scene. Ms. Bayless later died from a “massive stroke.” The 7 minute call can be heard HERE in its entirety. A couple of other things made known in the case were that the senior living community did not have any trained medical staff. Remember – the facility was similar to an apartment house. In addition, Ms. Bayless had made known her intentions to “die naturally…without any kind of life-prolonging intervention.” According to the family, Ms. Bayless knew that there were no medical staff when she decided to live at the facility. So why am I in shock? Look at all the whacked out opinions that are being generated from this case. Some people demand criminal charges be filed against the people who wouldn’t help. One person recommends “Depraved Indifference Homicide” Another person notes that if a law says that “you cannot deliberately withhold medical care from a dying person” then ignorance of the law is no excuse for failing to act – applying that hypothetical to this case, of course. Bakersfield California police are looking into whether there was anything criminal and the county Aging and Adult Services Department is determining whether “elder abuse” may have taken place because of the incident. The thing is that if criminal charges were appropriate, then everyone in the dining room of the senior living facility who saw Ms. Bayless collapse would have to be thrown in jail. No one helped her. Let’s just charge everybody with a crime. California can’t pay its bills as it is, so it is unlikely that they will criminally charge a group of elderly patients requiring nursing care and then be required to provide continuing medical care to them. Maybe they’ll all get electronic monitoring bracelets and weekly visits via the wheelchair van to a parole officer, instead. Then the “experts” across the news stations pile on. Virginia Commonwealth professor of geriatrics Dr. Peter Boling stated that without advance directives, patients “wind up sometimes in a very painful and trying situation.” This quote seems to acknowledge that patients may receive unwanted CPR if  there is any question about a patient’s wishes. CBS legal analyst Jack Ford calls the actions “morally reprehensible” but also notes that our society has become much too litigious. Ah, but what about California’s Good Samaritan statute? It exempts people who provide emergency care from liability for civil damages, but it also contains exceptions. Providers have to act in “good faith”. It doesn’t apply to those who are grossly negligent. And it doesn’t apply if the provider is being compensated. Employees of the senior living facility are, by definition, being compensated. So a plaintiff’s attorney may have the ability to circumvent the protections afforded in the Good Samaritan statute just through the “compensation” angle. Other people argued that the 911 operator took all liability for the actions of the nurse. How does such a promise, which is essentially a verbal contract, absolve the nurse from liability when the nurse is the one performing the actions? If a lawsuit was filed, the nurse would still be named regardless of the 911 operator’s ...

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Healthcare Update – 03-04-2013

Drunks caught on security camera beating each other in a Turkish emergency department waiting room. Best part of the video is when one dope pulls off his belt to start hitting people and his pants fall down. Then he waddles about swinging his belt like a little kid with a load in his diapers. Another bamblance theft from the emergency department. If you don’t know why it’s called a bamblance, you need to listen to the video below (strong language alert). This latest ambulance theft occurred at University of Michigan. Many of the commenters to the article suggested that the patient was going to a different emergency department due to the wait times. httpv://www.youtube.com/watch?v=bBa0blUoE8U FDA stifling pharmaceutical innovation through excess regulation. You don’t say. Scary that the average time and cost involved in developing a single drug approved by the FDA is 12 years and $1.2 billion. How much will you be charged for your emergency department visit. This study in PLOS-ONE gives you a good idea of what you should be charged. Keep in mind, though, that the numbers are “median” values, meaning half of patients got charged more than those numbers and half of patients were charged less than those numbers. The range of charges was ridiculous. For a UTI, the lowest charge was $50 while the highest charge was $73,002. That doesn’t mean some poor patients actually paid $73,000 for a Bactrim prescription, only that insurance was billed that much (which is still a crime). Yet another way for government to cut healthcare costs: Pay for services, then go back years later and allege that those services were provided inappropriately. Demand reimbursement and penalties. Publish news articles about how horrible the providers were and how patient’s lives were in jeopardy. Then show how federal agency intervention is the only means to help patients. In this article, nursing homes had patients on two whole anti-psychotic drugs and one depression medication and didn’t even have tons of paperwork to show how the drugs were being monitored! Gasp! Another patient had paperwork for the government, but the paperwork showed that he kept getting physical and occupational therapy even though all the therapy goals had been met. What “poor nursing home care.” Too bad we can’t compare private hospital performance to VA hospital performance on the HospitalCompare web site. Data for government institutions is blocked. Wonder why that is? One of the biggest impediments to the government providing health care to the general public is that it would be crushed under the weight of its own paperwork and regulations. Obama administration creates statistics showing that its policies have decreased the hospital readmission rates by a little more than one percentage point. A CMS official says that the news is “exciting” and that we are seeing “a fundamental, structural change.” Penalties work! Read into the article a little further and you’ll see that the penalties amount to a whopping $1 per Medicare patient for one hospital. You’ll also see that the government is penalizing 2,217 hospitals which is a little less than half of all the non-federal government hospitals in the United States. In other words, whether or not hospitals will receive penalties pretty much becomes a coin-flip. I’d like to see how many of those non-readmissions were classified that way simply because the hospitals admitted the patients as “observation” stays – meaning that more of the costs were shifted to the patients and that the number crunchers still met their goals. Doubt you’ll hear that sound byte from the administration, though. Interesting findings. When admitted patients receive “clot-buster” thrombolytics for acute ...

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Dear Diary

Lets see. What’s new recently? Wrestling is officially over for the year. I happened to be the “trainer” for junior’s regional wrestling meet. Was busy most of the day. It seems as if the coaches give kids Coumadin before the meets. I haven’t seen so many nosebleeds in a long time … except maybe last year when I was the “trainer” for a wrestling meet. Not only nosebleeds, but there were also head injuries, an eye injury, and a broken arm. Nothing some 3 inch tape and gauze pads can’t handle, though. During the match, I had a firsthand experience of why the UnAffordable Care Act isn’t going to help as much as many people believe. Again, it boils down to the fact that healthcare insurance doesn’t equal healthcare access. A dad walked into the meet and from a distance I could tell he was having difficulty breathing. He was stopping every so often while he was walking so that he could lean on the wall or sit down and catch his breath. He made his way over to me and asked for a favor. Could I write him a prescription for ciprofloxacin? He had these same symptoms with pneumonia in the past and that is what his doctor prescribed to clear it up. This dad is a great guy, but he doesn’t live the healthiest lifestyle. He smokes. He’s heavy. He drinks quite a bit. I also knew from previous discussions that he had a history of anemia. There were literally 10 diseases that popped into my head that could have been causing his trouble breathing – besides pneumonia. “You really have to go to the hospital. You need blood work and a chest x-ray, not a prescription for antibiotics. Besides, even if this is pneumonia, ciprofloxacin probably isn’t going to help. And if the pneumonia is bad enough to be causing you trouble breathing, you’ll need to be admitted anyway. This is serious.” “I can’t afford it. The doctor’s visit will be $75, the chest x-ray will be $250, and my insurance won’t pay for any of it. I am having trouble paying my bills as it is.” “But this is your life. I would rather see you have to pay a couple extra bills and be around for your kids.” “I’ll be okay.” I kept an eye on him during the meet, and he ended up leaving early. I even texted him later in the day. He wrote back that he was okay as long as he was laying on the couch. I told them that I could call some people at the hospital to see if we could get him discounted testing performed. He said that he still couldn’t afford it. I hope I don’t read about him in the obituaries. It just sickens me that our government provides no-cost “insurance” for poverty-stricken people who earn no money, but many of the working poor get nothing but a mandate. If we’re going to make the system better, why can’t the government provide access to health care for everyone? More funky dreams. A few days ago I had a dream that Mrs. WhiteCoat and I were walking back to my pickup truck after dinner. We got there and the driver’s side door was open. Someone’s leg was hanging out of the door. I walked a little closer and asked the person what he was doing. “Is this your car?” “Yeah, what are you doing?” Then he reached back inside the truck, grabbed a shotgun, and pointed it at me. I tried to grab my pistol and run ...

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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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