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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.

Healthcare Update — 05-01-2013

Doing a mini-update for now. More to come. Woman walks into hospital, goes to random patient rooms and tries to pry open machines infusing pain medication into IV lines. When that doesn’t work, she cuts the IV lines and steals the medications directly from the IV lines. Listen, lady. Hospitals are probably one of the more video camera-laden places in our society. Walking through a hospital will virtually guarantee that hospital security will have a picture of you … which they will then post on the news wire. Like this. Easier method: Go to Nurse K’s hospital emergency department, ask for Dr. FeelGood, and complain of bad back pain. Taking patients gone wild to a new level. Australian nurse has part of her breast bitten off during altercation with patient. Concern grows over the “rising tide of violence in the emergency department.” Well, if I’m going back to go to the Greybar Motel after my layover in the emergency department, I may as well try the ol’ bathroom escape trick. Tennessee inmate escapes from emergency department bathroom after getting a bathroom break. Caught shortly afterwards and is now charged with felony escape in addition to his other felonies. Pennsylvania’s Dr. Robert Childs bashes emergency department in letter of resignation to hospital. Criticizes emergency physicians for transferring a 7 month old with a burn to the hand to a burn center – where the patient was admitted for three days. States that he could have treated the infant’s burn by applying cream and bandages which would have cost about $150 and would have saved the family from traveling back and forth to the burn center. Those mean emergency physicians don’t trust doctors in our area so they ship them out of town. Oh, and they call and wake him up in bed at night, too. Bwaaaaaahhh. Hey, Doc … the criteria for transfer of burn patients (.pdf) include both burns involving the hands and burns in hospitals without personnel qualified for the care of children. When burns to the infant’s hand that you treat for $150 scar down and cause loss of function in the fingers, I’m sure the child and the family will be so pleased that you decided to save them money and drive time. You need to go read a book or two and pipe down with your silly letter writing. Then you can apologize to the doctors you bashed. From a reader … Here’s one for your long-suffering “bambulance driver” readers… “According to the incident report, Ferguson said she didn’t have a car and this was the only way she had to get around and Medicaid paid for it anyway. It was part of her benefits. “And all of those ambulance trips taken by Ferguson? “Each one costs $425, plus mileage. “Officials say what Medicaid doesn’t pay, taxpayers will have foot the rest of the bill, more than $400,000.” N.B.  She’s 51 and on Medicare, has been doing this for seven years (since she was 44), and thinks using ambulances for basic transport should have been part of the “benefits” she was “entitled to”.  We’re stuffed. Until providers and police prosecute thieves like this, I agree. We are stuffed. If this lady made hundreds of false police reports to get a ride to the police station or stole hundreds of FBI vehicles to take a drive downtown, she’d be in the Greybar Motel quicker than she could say “abdominal pain.” And think about the access to ambulance services that people with true emergencies lost while paramedics were playing Driving Miss Daisy with this woman. From another reader ...

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Health and the Human Microbiome

I’m personally a strong believer that the interaction between our diets and our mircobiome affects our health in more ways than we realize. I think we are just starting to scratch the surface of the ways in which our microbiome keeps us well. Given that, I found a couple of recent medical studies quite interesting. First was a fascinating correlation between diet and heart disease. Presence of trimethylamine N-oxide or TMAO is a strong predictor of arterial placque accumulation in patients. Arterial placque rupture is what causes heart attacks and some strokes. TMAO levels are increased in patients who ingest carnitine – which is abundant in red meat … and energy drinks (where the ingredient is listed as “L-carnitine”). The part of the study that I found most interesting was that people who didn’t eat a diet high in red meats – vegetarians, for example – did not  produce TMAO when fed a high-carnitine diet. Researchers also found that mice which were given broad spectrum antibiotics to wipe out their intestinal flora did not produce TMAO when fed a high-carnitine diet, either. In other words, the composition of the intestinal flora within the human gut seems to affect ones ability to produce TMAO. The study didn’t prove causation, but a diet high in red meats and/or energy drinks is correlated with elevated TMAO levels. The hypothesis that still needs to be studied is whether a high-carnitine diet encourages the growth of flora that converts carnitine to TMAO – or whether it may inhibit growth of some intestinal flora that stop the conversion. A link to the actual study article is here. Similar data was published 2 years ago, so it isn’t exactly a novel concept, but I still find it fascinating. Another study showed the relationship between weight loss and gut flora Gastric bypass surgery causes weight loss. Initially, it was believed that the bypass itself caused the weight loss. These researchers took gut flora from mice who had undergone a gastric bypass procedure and implanted them into mice that had no surgery. The transfer of bacteria alone caused weight loss and decreased fat mass in the mice who never had the bypass surgery. Still another diet/health study showed a correlation between intake of fruits and decreases in hot flashes during menopause. More fruit, vegetables, pasta and red wine – similar to a “Medirerranean-style” diet – was correlated with a decrease in the incidence of hot flashes and night sweats by 20% during menopause. When I read stories like these, I always start thinking about “causation” instead of correlation. For example, in this case does a Mediterranean-style diet cause growth of bacteria that inhibit hot flashes and night sweats? If so, do other diseases that cause night sweats (say lymphoma or tuberculosis) affect the same bacteria? And if so, could changing the bacterial flora in the gut affect those diseases? I know. I know. Disengage the clutch, WhiteCoat. You’re thinking too hard. Then again, I remember when I was a medical student and our highly esteemed professors taught us that most ulcers were caused by “stress” and “Type A personalities” — until Helicobacter pylori was discovered.

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A Free Meal

“What’s their problem?” The nurse was both upset and frustrated. The patient was a 16 year old young man. He had a fever for a few days and was vomiting … like half the other patients in the emergency department this week. Unfortunately, his mother was a hospital lab tech, so she knew a little bit about a lot of things. Her requests started about 20 minutes after they were placed in a room. “Can’t you just line and lab him before the doctor sees him?” He didn’t look that bad. Membranes moist. Vital signs were acceptable except that his heart rate was in the 140 range. OK. Fine. Here’s some IV fluid and we’ll do a couple of labs. The nurse missed the first IV. The mom refused to let her try a second stick. “Nope. You get one chance only. Call someone with more experience.” So they had to call the IV team. Which took more than an hour to arrive because they were so busy. In that time, the mom requested two pillows, blankets, grape Gatorade, and some IV Zofran. When the IV team showed up, the mom wanted the patient to have D5 .45NS instead of normal saline. After all, he hadn’t eaten in a few days and could use the extra sugar. Then the patient’s father arrived. He was reportedly a physician from another country who hadn’t been licensed in the US yet. Why hadn’t we tested the patient for sinusitis? At least we needed an x-ray of the sinuses. After trying to reason with the doctor that sinus xrays are a poor method of determining sinus inflammation, that the patient had no symptoms or sinus infection, and that the treatment wouldn’t change anyway, we just ordered the x-rays. Press Ganey scores, you know. Oh, and in case you were wondering, the x-rays were normal. All the labs were also normal … except a WBC count of 14. Great. Doctor says “obviously that means he has a bacterial infection, what are you going to do to work it up?” So we went further down the rabbit hole. More fluids. Add urinalysis and a chest x-ray. “How do you know he’s not septic?” The fact that he’s sitting there smiling and texting people on his iPhone 5 was probably a pretty good indicator. I wonder if they’ve ever done a study about iPhone use in the emergency department and severity of illness. “He doesn’t really appear septic to me.” “But what about his elevated pulse and his fever?” Flashbacks of a certain New York Times article and wayward journalist came to mind. OK, we’ll add blood cultures and a lactic acid. The nurse mentioned that it almost seemed like they wanted the patient to have all this testing done. I agreed. The rest of the tests came back normal. Finally the patient’s pulse was in the 110 range. I broached the subject of discharge. “Did you do a flu test?” “He doesn’t have symptoms of the flu. And even if he did, he is outside the treatment window, anyway. Recall that his symptoms started a few days ago.” “Maybe you could prescribe him Tamiflu just in case.” “I’m sorry, but Tamiflu isn’t indicated for your son, the medication is expensive, and it has side effects.” “Oh, and can you at give him some Claritin D before he leaves?” “No. We don’t have Claritin D in the emergency department.” “So can you at least give us a prescription for Motrin and Tylenol?” “A prescription? You can pick that up at the dollar store over the counter, you ...

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Facing One’s Own Mortality

I met a unique patient not too long ago. She was having back pain. Yeah, one of those patients. We helped make her pain better, but the story behind why she had her back pain and her attitude made a lasting impression on me. The patient was in her 50’s. She had smoked through most of her younger life, but then decided to stop about 5 years prior to developing her back pain. Always seems to happen that way. About 4 months prior to her visit, the patient began coughing up small amounts of blood. A CT scan showed she had advanced cancer. There was a large tumor mass about the middle of her lung and it appeared to be growing into the major blood vessels in her lung. She had seen several surgeons who all believed that the tumor was in too delicate of a place to try to remove. Chemotherapy and radiation therapy had only a minor effect on the tumor and caused the patient to have all kinds of side effects. So she was stuck. No treatment available. Her oncologist told her and her family that at some point, the tumor would eat through the blood vessel and that she would bleed to death. It might happen tomorrow, it might happen in a year. There was no getting around it. Her death would be bloody and quick. The doctor suggested that the family keep several dark-colored towels around the house to mop up the blood. Pragmatic advice, but not exactly empathic or very encouraging. The thing that made the biggest impression on me was the grace and dignity with which the patient carried herself. I was very interested in her story and how she was coping with her terminal diagnosis. She didn’t mind talking about it. As she relayed her story, it definitely wasn’t the typical progression through Kubler-Ross’ stages of dying. She was depressed upon hearing that the cancer was no longer treatable and she was scared that she could die at any minute. She didn’t want to be around anyone or leave the house because she didn’t want them to witness her bleed to death. That lasted about a day. Then she became determined not to spend her last days sitting in her bedroom being afraid and depressed. So she accepted her condition. She accepted that she wasn’t going to see her grandchildren grow up and that she wouldn’t get to spend another Christmas with them. She made an active effort to fully enjoy what life she had left with them. She carried a dark towel around with her everywhere she went. She figured that when the time came, she could lay on the floor and vomit into the towel so that others wouldn’t see the blood or have to clean up as much. She wrote notes to all of her family members on a regular basis. Small notes. But they all told the family members how happy they made her and how much they improved her life. She also kept a note in her pocket that she planned to pull out so that anyone seeing her vomiting blood and dying in front of their eyes would know what was happening, why it was happening, and to thank them for trying to help but also let them know that there was nothing they could do to help her. She was still afraid, but she really did appear to be enjoying her life. As I shook her hand, she smiled and said “Thanks for making an old lady’s final days a little more comfortable, doc.” I ...

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Healthcare Update — 04-23-2013

Also see more Healthcare Updates on my other blog at EP Monthly.com New York family wins $130 million in medical malpractice lawsuit stemming from obstetrical negligence case where patient was born with cerebral palsy. The back story to the verdict is even more wild. The plaintiffs rejected an $8 million settlement offer, then lost the case at trial. An appellate court reversed the verdict and the case was tried a second time, resulting in a hung jury. The third trial resulted in the $130 million verdict. Georgia hospital gives up fight to erect a freestanding emergency department. State denies request because the area “already has plenty of emergency services and that the proposals failed to demonstrate the need for new services”. Ever wonder why the state only controls hospital construction? Why doesn’t the state say that areas already have plenty of strip malls or Burger Kings or banks and deny building permits to those businesses? Hospital in Nevada accused of “patient dumping” by giving psychiatric patients one-way bus tickets to California. The article doesn’t say whether the patients are prematurely discharged from the Nevada hospital before being sent to California, but if not, California officials are certainly stretching the definition of “patient dumping”. Ohio man found intoxicated and cursing in Kettering Medical Center ED. Taken outside by police and wants bus ride back to VA. Good thing this wasn’t California or the police would have been accused of patient dumping for bringing him there. Couldn’t resist clicking on the link after reading the headline. Seven Things Teenagers Can Do To Stay Out of the Emergency Room. Ultimately the advice, such as avoiding guns, avoiding drugs, and regularly exercising, is common sense … but then again, if some teenagers used common sense they wouldn’t end up in the emergency department, so the advice is worth repeating. Patients gone wild. Perhaps more appropriately patient families gone wild. Stabbing victim brought to ED in Albany, GA, then victim’s family attacks stabber. A doctor and several nurses were pushed in the melee by a friend of the victim, apparently for “taking their time” when the perpetrator, one Quantavious Thomas, wasn’t sure whether or not his friend was still alive. “Ever hurt anyone?” It’s like a story line from that canceled Fox TV series Mob Doctor. Cleveland Clinic emergency nurse tries to hire an emergency room patient to kill someone over a property dispute. Now the nurse will be wearing striped scrub suit in the Greybar Motel. Does a charge of $2500 for a five mile ambulance ride and $1900 for a “60 second” emergency department visit demonstrate a need for universal health care? I don’t think so. Changing the payor won’t necessarily decrease the charges. Another thing I found interesting with the article was the number of commenters who weren’t as concerned with the charges as they were with making sure that someone else was paying for them. Eventually that “someone else” trickles back to all of us. Expanding liability for medical malpractice. A cancer patient was moved to a long-term care hospital where the patient was made a DNR without the patient or his wife agreeing to DNR status, then was started on “comfort care” measures and allegedly died from an overdose of pain killers. An autopsy listed the patient’s death as an overdose and listed the manner as an “accident.” If plantiffs can show that the hospital’s actions were “willful, reckless, or a felony,” then New Jersey’s medical malpractice caps on non-economic damages don’t apply. I’m torn on this case. On one hand, do we want the Liverpool Pathway to be instituted in ...

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Refusing Number 12

A 16 year old patient came with her mother to the emergency department for another “kidney stone.” She was having lower abdominal cramping – mostly on the left – which had been present for the prior two days. The pain was dull and was worse when she urinated. She was sure this was a kidney stone because it was just like the twenty or so kidney stones that she had in the past. “Wait a minute. Did you say ‘twenty’?” “Yeah. Twenty.” I immediately started asking about whether the patient had been worked up determine why she kept having kidney stones. She had been diagnosed with hypercalcuria – high calcium levels in the urine. When the levels of calcium are high in the urine, then calcium is more likely to precipitate out and create stones. Her calcium levels were chronically high and her pediatric urologist couldn’t figure out why. And she was in a lot of pain from these kidney stones. I ordered a few labs, some Motrin and some IV fluid, then went to look through her old medical records.  “Radiographic studies” tab showed 11 CT scans of the abdomen and pelvis plus at least a dozen ultrasounds over the prior 6 years – and that was just in our facility. Multiple different physicians, including family practitioners, urologists, and emergency physicians had ordered the different tests. On one of the CT scans about a year ago, there were multiple small calcifications in both kidneys. “Laboratory” tab showed 27 metabolic panels – each one with a normal calcium level. There were also six urine calcium levels – each normal or below normal. I printed out the labs and showed them to the mother. “Well her abnormal lab tests were at other hospitals.” “Which other hospitals? I want to get copies for our records.” “There have been quite a few.” “You can just give me a couple, then.” [ awkward pause ] Then the daughter interrupts. “It’s OK mom. I feel better now.” And so the patient and her mother left after receiving only a dose of Motrin. Neither appeared terribly pleased. I have trouble figuring out where the problem lies for the lapses in this patient’s care … The patient and her mother who doctor hop and get the same workups over and over again? Doctors who order the testing over and over again? Or maybe a system which creates no accountability? Perhaps a combination of all three. But how do we fix it?

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