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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 — 04-08-2013

Columbus, OH paper compares hospital wait times from 15 different hospitals throughout central Ohio. Metrics include minutes until diagnostic evaluation, minutes until pain medication, minutes until admission decision, and minutes from admission to room placement. I just wonder how accurate the metrics are. It isn’t like self-reported data like this can’t be manipulated. Evanston Northwestern Hospital in Chicago suburbs also making news because of its wait times – nearly twice the national average. The problem with providing patients with insurance: When the insurer cuts payments, what happens if providers won’t take your insurance? Government cuts payments to providers so that it costs more for cancer clinics to provide chemotherapy to some Medicare patients than the government reimburses. To stay afloat, some cancer clinics have now begun turning away Medicare patients needing cancer infusions. Now patients go to hospitals where the charges for cancer treatment are higher and the waits for treatment will likely be longer. But we’re going to be insured! And we can keep our doctors, too! Patients gone wild. Two brothers in Lebanon “attack” an emergency department, smashing windows and insulting the doctors and nurses on duty. In other words … a normal day in a typical American emergency department. And their Press Ganey scores probably stink for that day, too. What a great story. Six year old Long Island kid treated in emergency department raises $275 with a fundraiser and uses the money to buy coloring books for other emergency department children. Remember how CMS promised to give incentive payments for “meaningful use” of electronic medical records? Not so fast. Rules changing. Now it is doing random audits of 5-10% of all applicants to see whether they should actually get their bonus payments. Self-reporting isn’t good enough any more. Wouldn’t it be interesting to see what would happen if all providers went back to paper records? Canadian paramedics visiting patients with “non-urgent” issues to keep them out of emergency departments. The only question I have is who determines whether the issues are “non-urgent”? A second interesting Medical Economics article. What are the tech trends that will affect how doctors practice medicine in the future? Interesting to consider. Remote patient monitoring. Personal health records with biometric security. Cool stuff. More than 25% of Oklahoma patients enrolled in Medicaid. Of those, about a quarter used the emergency department a total of 528,000 times at a cost of $170 million. Oklahoma is now trying to determine how to deal with the high utilizers – those who use the ED more than 15 times every 3 months. Speaking about Oklahoma … Oklahoma Dentistry Board officials are deciding whether to pursue criminal charges against a dentist. Officials found rusty instruments, “potentially contaminated drug vials” and “improper use of a machine designed to sterilize tools” in the dentist’s office. The Oklahoma Dentistry Board accused the dentist of re-inserting needles in drug vials after their initial use and using the same drug vials on multiple patients. This happens often in medicine. The dentistry board also stated that a sterilization machine hadn’t undergone monthly testing in six years. Concerning, but when the Board officials tested the machine was it not properly sterilizing equipment? They did test the machine, right? Were the rusty instruments used on patients? Where was the rust located – on the handles or on the surfaces that come into contact with patients? In addition, the dentist allegedly allowed dental assistants to administer IV sedation when only dentists are allowed to perform such acts. For each charge, the dentist could face up to four years in prison and a $10,000 fine. Are the ...

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My Secret Addiction

By an Anonymous Emergency Physician Hi. I’m Anon. I’m a 44 year old emergency physician. And I’m an addict. My addiction came to light when my Press Ganey scores plummeted after I started to stand up to the chronic pain and frequent ER patients. The fact that I have an addiction was reaffirmed when I went to my state’s Prescription Drug Abuse Summit. When I saw so many professionals from varying fields (medicine, law enforcement, pharmacy, education, etc…) assembled, I realized my problem: I’m addicted to prescribing pain medications. As with any addiction, the first step in treatment requires acknowledgement of the problem. I thought back to how my addiction began. Coming out of medical school, there is a certain power that comes on the first day of residency. You suddenly have the power of the pen. You can write prescriptions for low blood pressure, high blood pressure, low blood sugar, high blood sugar, too many bowel movements, not enough bowel movements.  The list goes on and on. But one of the largest ways in which we can help patients is by treating their pain. Controlled substances. Yes, the new physician quickly learns that the pen wields an awesome power and an awesome responsibility. This feeling fades quickly in the face of an 80+ hour work week. Fast forward 5-10 years. You are seeing 10-12 patients at the same time, all the chest trauma goes across town, and you have a waiting room that is 20 patients deep, and you already know the medical history of ten patients waiting to be seen on the tracking board. Hospital administrators pressure you to make sure that all nonemergent patients are treated and released within 90 minutes. All admits must be up to the floors within 240 minutes … if only the medicine consultant would get down and actually see the patient. It’s not uncommon to see 40 or more patients in a shift. I make it a point to look up the prescription/controlled substance database our state has. This has been an absolute lifesaver to me and to several patients I have confronted. The problem is that it takes time: – 2 minutes to look up the patient and print off the list – Another minute to count up the number of prescriptions (it does take time to count to 50 or even 72 – my personal best record for one year) – Another 3-5 minutes to go to the room and confront a patient who has an issue – Then a few more minutes to sit down and document the conversation. So I have 10 minutes to evaluate a patient, create notes in an arcane electronic medical record, and discharge the patient. Yet all of that time can be taken up by doing what is right with drug seeking patients. I cherish the ability to “catch” someone who is diverting drugs, to be able to sit down with them and have that “aha” moment. I have even had a few patients come back and thank me for confronting them. But my worth is partially measured by the number of patients I see per hour. My worth is also partially measured by my patient satisfaction scores. It’s not all possible. Why do I and so many other physicians have this addiction? NOT providing the prescription is very hard. It takes time to do the research on the patient. Confronting the patient with a problem is emotionally draining. Doing it 5-10 times in one shift is not only a reality, it is downright crippling. It sucks out last bit of energy out of ...

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What’s the Diagnosis #16

A nursing home patient is brought by ambulance with a cough. Nursing home staff believe the patient may have aspirated lunch 30 minutes ago. The patient’s workup is normal except for his EKG which is shown below (you can click on it for a much larger/printable version). What’s the diagnosis? What needs to be done with the patient? Does it make any difference whether this was a new finding or an old finding? I’ll provide the answer in the comments section in a couple of days.

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Healthcare Update — 04-01-2013

This case report is entirely bizarre. Patient gets awarded more than $800,000 after visit to doctor resulted in incorrect diagnosis of cancer when the patient really had pneumonia and caused patient to have amputation of her foot. A trial was held on the case four years ago with a verdict in favor of the doctor, but the judge declared a mistrial because Washington State jurors were referring to the plaintiff’s Japanese attorney as “Mr. Miyagi” and were making other racist comments against him. Then, the article notes that the doctor had been disciplined by state regulators for making “erroneous diagnoses” and for prescribing methadone to drug-addicted patients. So now Washington State physicians’ licenses can be on the line for failing to perfectly diagnose patient symptoms and for prescribing medication for one of its intended uses. I admit we don’t have all the information behind the license actions, but the article makes the Washington State Medical Board sound a little overeager to discipline physicians. Congratulations! You delivered a healthy 6 month old! 15 lb 7 oz baby delivered vaginally in UK. More than 20 doctors reportedly assisted in the delivery. Curing patients gone wild? Australian hospital emergency department guards petitioning to carry guns at work. Medical workers claim that it will make emergency departments more dangerous. Australian patient held four days in emergency department waiting for psychiatric bed to open up. Shortage of beds creates high demand. Patient’s mother alleges that his condition worsened because of the long wait. Not that anything like this could happen in the US. Oh wait. What a coincidence. LSU is closing their mental health emergency department, resulting in other hospital emergency departments having to care for “an additional 2,000 people who are a danger to themselves or others, who are desperately in need of stabilization and potential further hospitalization.” When medical services are curtailed, the patients needing those services don’t just disappear.

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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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