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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.

Dear Diary

My gosh. I actually get angst when I haven’t posted for a few days. Actually, I have angst for other reasons, but not posting just adds to the angst. So what’s been happening lately? First, the poor WhiteCoat children are having trying times in their love lives. Oldest daughter WhiteCoat found out from a member of her track team that her boyfriend of 6 months was cheating on her. Another member of her track team was apparently going around and telling everyone that she had a “secret boyfriend” and was also telling everyone the sordid details of the interactions she was having with her “secret boyfriend.” So daughter WhiteCoat dumped Mr. Two-Timer. Mrs. WhiteCoat called his parents to let them know what was up. Papa Two Time said that he didn’t know what we were so upset about because the other woman “pushed herself” on Daughter WhiteCoat’s ex and that the other woman was a “two bit whore” anyway. I’m kind of thinking that this breakup was a good thing. The next day, Junior WhiteCoat’s girlfriend texts him and says she “wants to be single.” The text gets posted to Instagram. Then about 60 comments later, there are accusations flying back and forth that she’s been dating someone else and that he deserves better. When I was 12 years old, I was climbing up trees with a bag of tomatoes and tossing them at cars. Now my kid is 12 and he’s in need of relationship counseling. Health hasn’t been great lately. Pretty much every person in the family has had vomicking and/or diarrhea in the past week. Zofran is our friend. But it gets a little frustrating when you’re working in the ED and patients who puked once or who have had a couple of loose stools want work notes to be off for the rest of the week. Got kind of a kick out of one patient walking into the emergency department as I was leaving work. He was heading toward his car in the parking lot and I saw him suddenly turn around and head back toward the hospital. He was walking like he had a load in his pants. He gets closer to me and he starts shaking his head. “Ya try to do the right thing and what happens? It bites you in the ass. I’m holding in my gas in the ER and I waited until I get outside to pass it … then I crapped my drawers.” He did have a load in his pants. Although if he passed gas in the ED, it probably would have been just as embarrassing. Grandma and Grandpa WhiteCoat have been having issues. Their health has deteriorated to the point that they were unable to stay independent, so they moved in with my brother. The only problem is that Grandma WhiteCoat has a few cats … like 10 … and that Grandpa WhiteCoat has a book collection … like about 30,000 … all in boxes. He also has a good thousand or so small plastic boxes of pictures that he has taken through the years. All categorized, but none of them ever seen by anyone but the person at the photo lab who initially developed them. And if you want to look at one of them, you can’t take it out of the house because you may copy it and the pictures are copyrighted. Fortunately, he converted to digital pictures about 7-8 years ago, so now it’s just a matter of storage on his computer drive and no additional plastic boxes. But then he sends pictures to ...

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Healthcare Update — 03-25-2013

Another medical issue with overweight patients: Intramuscular injections. An Epi-Pen may not work in patients who are obese since the distance through the subcutaneous fat to the muscle is greater than the length of the needle. This study showed that in more than 4 of 5 obese children, the subcutaneous fat layer was too thick for an IM injection one quarter of the way down the thigh. In nearly 1 of 5 obese children, the subcutaneous fat layer was too thick three quarters of the way down the thigh. In those patients, the study suggested injecting the calf. I suppose the manufacturer could be forced to make autoinjectors with longer needles, but then non-obese patients would theoretically risk getting a bone marrow injection of epinephrine. How good are emergency physicians at dispositioning psychiatric patients when compared to psychiatrists? Not horrible, not great. 95% of patients assessed as “definitely admit” were admitted by the psychiatrist. For other emergency department psychiatric patients, there was an 87-90% concordance rate. Sugary drinks may kill 25,000 people each year. That’s nothing. SALT [allegedly] causes one out of 10 deaths in this country each year and more than 2.3 million deaths worldwide in 2010. Wonder what that sphincter Michael Bloomberg is going to do with this information. Salt tax? Force NY City hospitals to draw serum sodium levels on all patients? Outlaw salt shakers in restaurants? Or maybe he could just go after the salt shakers with the larger holes and call them “asSALT” weapons. Bwaaaaaahahaha. Sometimes I crack myself up. Another nice article by Alicia Gallegos at AM News. Liability involving patients who overdose on medications is increasing. Families of suicidal patients who overdose on medications are blaming physicians who prescribe the medications … and winning. According to the article, physicians are having also disciplinary actions taken against them if they prescribe medications to a “doctor shopper”. This is getting ridiculous. When pain patients complain that they are treated like “drug seekers,” this is part of the problem why. Maybe the next step should be forcing all patients to sign a statement requiring them to list any doctors that have prescribed them medications, any medication that they have at home or have access to at home, and any medications or street drugs they are using or have used in the past 12 months.

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Healthcare Update — 03-18-2013

The Veteran’s Administration intentionally changed and hid data to avoid providing costly yet critical medical care to soldiers from the Gulf War? A head VA epidemiologist alleges that more than two thousand veterans responding to a study felt like they would be “better off dead”. In 95% of those cases, the VA did nothing to assist those veterans with follow up care. In a subsequent study when the same epidemiologist attempted to ensure follow up care for potentially suicidal veterans, he allegedly had disciplinary actions instituted against him. If that’s true, I wonder how everyone else will be treated once they have medical insurance under the UnAffordable Care Act. American College of Obstetricians and Gynecologists advises against using the da Vinci robots for hysterectomies. Robotic surgery adds about $2000 to the cost of surgery and “there is no good data proving that robotic hysterectomy is even as good as, let alone better than, existing and far less costly minimally invasive alternatives.” I hope that other specialty societies have the integrity to make similar inquiries. All those hospitals that spent millions of dollars on these machines to keep up with the Joneses may just be in for a big surprise. Insurance companies expect health insurance premiums to rise 20% to 100% once the UnAffordable Care Act is implemented next year. Department of Health and Human Services responds that it is misleading to look at the one provision of the UnAffordable Care Act because “taken together, the law will reduce costs.” Well, gee, that broad unsubstantiated assertion sure convinced me. You know all those things your hospital does to stop the spread of clostridium difficile infections? Yeah. They don’t work (.pdf file). 42% of hospitals implementing such policies noted decrease in c. difficile rates while 43% of facilities noted an increase in c.difficile rates. Can’t wait to see the spin that the Joint Commission puts on this one.

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Comic Relief

Courtesy of mednificentcomics.com Not quite a case medical student’s disease, but close. Have to love it. The thing is that when I was a medical student, there wasn’t an internet and there definitely wasn’t a Dr. Google. So we were a lot more stressed out because we had to rely on the advice of our professors – who weren’t always that well versed in the diseases.

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Healthcare Update — 03-11-2013

Doctor treats child born to HIV positive mother with full three-drug regimen of HIV drugs one day after birth instead of one or two drug regimen typically used until an HIV infection can be confirmed. Treatment continued for 18 months, then the patient’s mother stopped bringing the patient to appointments. The child is now 30 months old, has been off HIV medications for a year, and has no HIV infection according to ultrasensitive testing performed at Johns Hopkins. Now the doctor’s colleagues are planning a celebration. Of course, if the child did poorly or had a bad reaction to the medications, the doctor would likely have been arrested, lost her license, and sued for millions. More warnings about superbugs. MRSA is bad enough, but what happens when the organisms living in all of our intestines become resistant to antibiotics? Patients gone wild returns. Minnesota goof screams profanities and disrupts medical care. Tied down in four point restraints until police arrive. Will likely be charged with disorderly conduct. Wow. If every patient that did this kind of thing was charged with disorderly conduct and whisked off to jail, our ED volumes would drop by a good percentage. Electronic medical records are supposed to improve care, right? In this study, alert fatigue caused 30% of VA doctors to miss important alerts. 87% of doctors said that the number of alerts they received was excessive and more than half blamed the design of the EMR for the problem. Quite possibly better than the lollipop story. Police find loaded gun in woman’s hoo hah during search. Also had crystal meth in her butt crack. And THAT, dear readers, is why they call it “dope.” You think your wait in the emergency department is long? Try going to LA County Medical Center where the wait averages 12 hours at some points. In the past, certain people have equated high wait times to a poorly run hospital, but we won’t go there. Spider bites may be a common complaint when coming to the emergency department, but the complaint often turns out to be a MRSA infection. As the Milwaukee Brewers General Manager discovered, bites from other arachnids may also require an emergency department visit when you try to squish them up in a tissue. British Columbia emergency physicians describe horror stories in their emergency departments allegedly due to funding issues and overcrowding. Performing CPR on the waiting room floor? Even I haven’t heard of that one before. Nurse in New York caught stealing medications from nursing home patients. Not sure how to take the wording in this article. Polish man walks into emergency department with screwdriver sticking two inches into his forehead, article reports that there was no damage to the patient’s brain. South Carolina inmate grabs an officer’s gun during emergency department visit. Second officer “fires shot to subdue him” – inside the emergency department. Inmate then gets taken back to jail. What happened to the gunshot wound? Did medical malpractice kill Bruce Springsteen’s saxophonist? Clarence Clemons’ brother, an attorney, pursues malpractice litigation against doctors for Clemons’ stroke. Could medical malpractice climate in Florida be changing? Bill working its way through Florida House would increase burden of proof on medical malpractice claimants and would limit who can serve as an expert witness. Also protects hospitals from liability for actions of their contracted health providers. Florida Medical Association attorney notes that Florida’s current malpractice laws are “doing a disservice to our state and are a driving force in a physician’s decision to leave critical-need specialities, retire prematurely and even leave to practice in another state.” We’re ...

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Should Refusing Medical Care Be A Crime?

Doctor threatens to call police on patient if she does not consent to immediate Caesarian section. The mother was a high-risk pregnancy (due to VBAC), was post-dates and had gestational diabetes. The fetus wasn’t in a good position to facilitate vaginal delivery, and an ultrasound showed the fetus in possible distress. The patient was sent to Tampa General hospital for immediate C-section, but refused to have the surgery done that day. She wanted the baby delivered on Friday, not Tuesday. So the obstetrician sent her an e-mail which stated, in part I am deeply concerned that you are contributing to a very high probability that your fetus will die or your child will incur brain damage if born alive. At this time, you must come in for delivery. I would hate to move to the most extreme option, which is having law enforcement pick you up at your home and bring you in, but you are leaving the providers of USF/TGH no choice The doctor was promptly contacted by the National Advocates for Pregnant Women, whose New York attorneys advised him (apparently applying their vast knowledge of Florida law to the case) that he was making “legally and ethically unjustifiable” threats and demanded he cease taking further action against the patient. The NAPW even put up a post about the incident on their web site. Hopefully, the attorneys at NAPW have licenses in Florida, otherwise some might consider them to be practicing law in Florida without a license – which I think might be illegal. Now the patient is having her baby delivered on Friday as she wanted. When I initially read this article, I was upset with the doctor. The more I thought about it, though, the fetus has as many rights as the mother does. If the mother was doing things to endanger the life of the fetus the day after it was born, a call to the police would be expected, not ridiculed. States mandate reporting of suspected child abuse and impose liability on providers if suspected abuse is not reported. In this case, it is questionable whether a failure to deliver a child that is possibly in distress would be considered “child abuse,” but usually if there is a suspicion, a report is mandated. I side with the doctor on this one. And I probably would have called the state child welfare agency on the woman just to cover myself. This case will get ugly real quick if there are complications during the pregnancy or if the child isn’t born healthy. If the baby is stillborn, should the mother be charged with a crime?

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Suing Doctors For Patient Addictions

Nevada Senator Tick Segerblom proposes bill that would allow patients addicted to prescription drugs to sue doctors for prescribing the addictive medications and manufacturers for creating the medications. Patients can already sue doctors for prescribing medications if they can prove that writing the prescriptions violated the standard of care and that they have suffered damages as a result. But Tick wants to take the concept a step further. If the patient sues a doctor and wins, the patient should receive payment for rehabilitation, possible punitive damages, and attorney’s fees. It doesn’t matter that “addiction” can be either physical or psychologic and that there is no reliable way to determine when addiction occurs. Tick’s bill doesn’t define addiction. It also doesn’t matter that people can get addicted to pretty much anything … alcohol, illegal drugs, porn, gambling, even collecting Cabbage Patch Kids. Tick’s bill only cares about those evil doctors. Beware internet service providers, you could be next on the list if your subscribers get addicted to the internet. But Tick has good reasons for proposing his bill. Since people lived without drugs before, Pharmacologist Tick doesn’t believe that drugs are the only way to treat pain now. That’s true. Patients in cancer pain could always try incantations and faith healing instead of popping pills. Or patients in pain could bust out some whiskey and a bunch of bullets to bite on … after they take anger management classes so they can purchase the bullets. Oops. That’s Florida. Sorry. Wrong state. Double oops. Alcohol could be addictive. Bad example. Besides, since children are allegedly taught from an early age to do whatever the doctor says, Neuropsychologist Tick says no one has the free choice whether or not to take addictive pain medicines. It’s not so much that, at least according to his Twitter feed, Tick seems just all … well … tickled … about seeing his proposal published in newspapers. The scary thing is that people like Tick Segerblom are elected to public office and may be able to regulate our lives. More comments at Overlawyered.com

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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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