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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.

CMS Announces New ICD-10 Code for Sleeping Nursing Home Patients

Wondering if GomerBlog has any openings … In its continuing effort to improve the accuracy of medical coding, the Centers for Medicare and Medicaid Services has announced a new ICD-10 code related to emergency department medical care. CMS spokesperson Marcella Skinner explains: We have noticed an increasing trend of payments for emergency department patients sent from the nursing home in the middle of the night for evaluation of lethargy and being difficult to arouse. Initially, this appeared to be an anomaly, but when we analyzed the data over the past 10 years, we saw that this phenomenon has been occurring even before implementation of ICD-10, but under a different billing code – V60.5 (patient caregiver wants an afternoon off). Of course, this new code will be paid at a lower level since all patients in REM sleep are difficult to arouse, but at least it helps us track the sleep/wake cycles of our nation’s nursing home residents. The new CMS ICD-10 code will be ZZZ317x – “Difficult To Arouse Due To REM Sleep – Nothing Really Wrong.” This code will supplement current ICD-10 codes of FULMA06c – Difficult To Arouse Due To Annoyance with Nursing Staff and OOPS08a – Difficult to Arouse Due to Previously Unnoticed Rigor Mortis. Dr. Laurence Carmichael, Director of the VA Medical Center in Plucksburg, VA applauded the new change. “For years we’ve been making up symptoms so we get paid when wide awake smiling nursing home patients get transferred to the emergency department in the middle of the night. Now the government has finally recognized our plight and has created this new easy-to-remember code so that we can be compensated for our services. What a great step forward!” Mary O’Leary, president of the American Nursing Home Association, had no comment. ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me.

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Healthcare Update — 01-28-2016

All those antibiotics for ear infections early in life may be causing your children to develop asthma and obesity later in life. Antibiotics appear to cause long-lasting changes to the mibrobiome – even when the microbiome returned to baseline several weeks after the antibiotics were finished. Macrolides (i.e. the much-coveted “Z-pak”) seemed to be the worst offenders, although amoxicillin also had a weaker but similar effect. Seen somewhere on Twitter. Enter your age and gender and this web site will tell you how you’re most likely to die as you age. Kind of creepy. External causes tend to predominate for younger people. Cancer and cardiovascular problems dominate for older folks. Child reportedly develops scurvy from drinking almond milk. Symptoms – including bone fractures and rash – improved with Vitamin C supplementation. The implication is that the almond milk caused the scurvy, but keep in mind that cow’s milk has very little Vitamin C, so it was a complete lack of Vitamin C in the diet, not just a switch from cow’s milk to almond milk. Why drink almond milk when “breast is best”? In fact, a new antibiotic developed from human breast milk could help treat superbugs in the future. The protein lactoferrin reportedly kills bacteria, fungi, and viruses on contact. Big Pharma doesn’t want to hear about breast milk as a way to fight superbugs. They want incentives, dammit. Antibiotics are only used sporadically and are generally don’t generate as much profit, leading many manufactures to abandon antibiotic research. Drug companies therefore want “prompt reimbursement” at higher prices to incentivize research. Here’s a better idea. Make antibiotics a controlled substance to stop people from prescribing them for every runny nose and cough that they come across each winter. Reduction in antibiotic use causes reduction in resistance. Although some may disagree … Pure awesomeness. If you ever want to see examples of the difference between “causation” and “correlation”, just visit this site. For example, US spending on science, space, and technology is 99.79% correlated with suicides by hanging, strangulation, and suffocation. Obviously we have to stop so much spending on science. It’s for the children. Irish hospital canceling elective surgeries due to overcrowding. Instead, surgical wards are being used to accommodate patients admitted from the emergency departments.

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Defibrillating with Soup Spoons

So I’m treating this patient the other day. He’s a little intoxicated. Got whacked in the head and needed some staples to close his scalp laceration. When I’m fixing patient’s various injuries, I feel like a barber sometimes. I strike up conversations … ask how their families are doing … how did they get in this predicament … that type of thing. This fellow comes straight out with a doozy. “When I was growing up, our next door neighbor was famous.” “Really, why?” “The husband was a surgeon in a small town hospital. There was a kid whose heart stopped beating after surgery and he saved the kid.” “That’s awesome. What did he do?” “He used two spoons to defibrillate the patient back to life.” “Spoons. Like silverware?” “Yup. Heart started beating and he lived.” By this time I already messed up one staple trying to process what happened. “Wait. Wait. Wait. He used two spoons. How did he keep from being shocked himself?” “I don’t know.” “Mmmmm hmmm. And what did he use for an electricity source? A car battery or something?” “Nope. A fan cord. He ripped it out of the fan and wrapped it around the spoon.” “Mmmmm hmmm.” “In fact, there was a story in Time Magazine about him.” “Mmmmm hmmm. Wow. That’s a great story. Must have been a great doctor.” “He was. Nice guy, too.” I don’t even know why I bothered, but I wrote myself a note to look this up online. Snopes.com … nothing. So I did a search on DuckDuckGo.com with “doctor spoons fan cord”. First result? Time Magazine. October 1959. Dr. Russell Simonetta defibrillated a 19 year old whose heart stopped after surgery – using spoons and an electrical cord. Whiskey Tango Foxtrot. One of the reasons I love my job so much is that I couldn’t make stuff like this up if I tried. I owe this guy a beer.

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Healthcare Update — 01-18-2016

As if stool transplants weren’t bad enough … Now some people are recommending urine cocktails to treat illness. Retiree in London was diabetic, had kidney problems, and swollen ankles. After starting to drink her own urine, she is suddenly cured and looks like Taylor Swift! OK, she really looks like Bea Arthur, but her kidney problems went away. Article tries to legitimize the urine drinking experience by noting that women already take medicine made from urine of pregnant horses – Premarin. Another person interviewed for the article rubs urine on his face every day as a skin treatment. Oh, and drinking urine is supposedly in the Bible, too. As I told my kids … “Urine BIG trouble if you ever try this.” Florida’s Medicaid managed care becomes more like Medicaid managed REFUSAL of care. With private companies now operating the system instead of the state, the added requirement of prior approval for many services and dealing with a myriad of billing procedures and rules are just two areas that are far more complex. “In this area, there are four different plans with four different sets of rules, four different provider handbooks, four different billing processes,” said Maggie Labarta, the president/CEO of Meridian Behavioral Healthcare, which provides mental health care and substance abuse counseling services in 10 counties. “For us, the administrative burden attached to billing has grown much more complicated. It is a lot of paper and a lot more bureaucracy.”  Some of the insurance plans will only pay for one day of the three days required for involuntary psychiatric admissions. Most plans require pre-approval for many routine services. As a result, Medicaid has become “more cumbersome and more difficult.” But don’t worry because the patients have INSURANCE! Award-winning screenwriter, producer, and director goes to Quebec hospital with abdominal pain. Later found unconscious in waiting room ultrasound showed ruptured aortic aneurysm. Newspaper claims patient was “denied potentially life-saving surgery.” Hospital reportedly revoked the privileges of its only vascular surgeon as part of Health Department reform and budget cuts. Patient was transferred to another hospital but died before he could make it to surgery. This patient had insurance, too. Interesting concept. When state laws become too onerous for doing business, companies close shop and leave. GE leaving Connecticut due to Connecticut’s high-tax, high-regulation, and anti-business policies and moving to Massachusetts which is presumably more business-friendly. California’s MemorialCare Health System wants to close a hospital and emergency department in San Clemente and replace it with an outpatient medical center and urgent care center – that wouldn’t be required to take ambulance runs. I wonder why that is. San Clemente residents fighting the proposed closure of the emergency department. California legislators refused to allow the new facility to operate as a stand-alone emergency department. As a result, there will be a 40 mile gap between the next closest emergency departments. Quite a bit of extra travel. Hope they have extra ambulances ready. When seconds count in a medical emergency, help will only be 30 minutes or more away. I’m sure a lot of those patients have insurance as well. Is that a hernia under your shirt or ….  Leicester patient finally has 8 in x 12 in hernia repaired. Before the repair, he was arrested for shoplifting when store clerks thought he had merchandise under his shirt. Yes, this patient had insurance, also. Shocked. Shocked I am. The Unaffordable Insurance Act continues to implode. 49 of 50 states will see premium hikes in 2016. The reporter is a little math-challenged, noting that “more than one in three states, or 17 percent” will see premium increases of 20% or more, but it doesn’t take away from the fact ...

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Dear Diary #20

Dear Diary This week has been hectic. Today capped it off. The emergency departments have been consistently overcrowded. We’re running at more than capacity lately. Patients are calling all the different emergency departments in the area to inquire about the shortest wait times. Some patients have even told me that they set their alarms for 3AM to wake up and come to the ED to avoid the wait. Still doesn’t work. The wait may be shorter, but there’s still a wait. And we haven’t even hit flu season yet. I’m worried what things are going to look like when that happens. One of the consultants on staff at our hospital is a jerk. I’m officially fed up with him and his attitude. He treats our secretaries and nurses like crap (which I didn’t know up until recently). I called him about one of his patients in the middle of the night. I’ve been practicing a while – longer than Craftsman the Consultant (see explanation below) – and had never seen a presentation quite like what the patient had. I described what was present on physical exam, labs, and x-ray, then gave him an idea of what I was thinking. He wigs out. “All you’re giving me is symptoms and physical findings. What do you want me to do about it?” “First, I also gave you x-ray and lab finds as well. Second, I’m looking for your help trying to figure this out.” “Well you have to admit you gave me a pretty piss-poor reading of the x-ray” “I’m not admitting anything. You want me to text you a picture of it so you can do a better job?” “No. That’s not the point! You’re supposed to be a doctor and you need to make a decision!” “Fine, I’ve decided that you need to come in and see the patient. Now.” “Who is your boss? Because I’m going to call him RIGHT NOW with this bullshit. You hear me?” “Don’t worry, you can talk to him when you’re explaining your attitude at the next Medical Executive Committee Meeting. I’m writing all of this conversation in the medical record and then forwarding a copy to the chair of your department and the MEC tomorrow morning.” “Whoa. Wait a minute. We’re obviously both a little upset. Now let’s figure this out.” “No, you’re upset and you’re coming in to see the patient so you can figure this out.” “I’m NOT coming in to see the patient. You can have her see me in the office in two days.” “Unacceptable. If you don’t come in to see the patient, then I’m admitting her and noting in the chart that it was because you wouldn’t come in at my request. Then you’ll get consulted on her for the morning.” “You do what you have to do.” “Don’t worry. I will. Have a nice evening.” The thing is, after the phone call, about four people magically appeared from around the corner and started high-fiving me. “That was great! Someone finally put him in his place.” “What a dick. It’s about time someone gave it back to him.” Only then did I hear about how miserable he’s been to other staff. So we decided to name him Craftsman – because he isn’t just a tool, he’s a power tool. Today pissed me off. I had planned to write several posts today, but it didn’t happen. First, Daughter WhiteCoat’s car wouldn’t start. When it did, it made some horrible grinding noise that sounded like the transmission is going bad. This is just after Mrs. WhiteCoat’s car needed $2000 in work (including new ...

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Healthcare Update – 01-06-2016

Study in American Journal of Clinical Nutrition shows that by consuming less sugar, our tastes change. Study participants who replaced 40% of simple sugars in their diet with fats/protein/complex carbohydrates rated foods 40% sweeter than control subjects who made no changes. The study suggests that, just as with so many other body processes, our bodies become tolerant of certain stimuli and we need more of the stimuli to obtain the same effect. In other words, we may be able to decrease our sugar cravings simply by avoiding sugar for a couple of months. Note how in the study, there was no difference between groups at the first month. The effects in the study took two months to become apparent and became even more pronounced at three months. Unfortunately, most people who diet don’t hold out for three months. Related article in Time Magazine. UK closing more hospitals to save money. Government stripping resources from emergency departments so that patients needing surgery have to be transported more than 40 miles away. Described as a “surreal situation – like a Wild West film set, with the fronts of the buildings in Main Street but nothing behind the facade.” The correct term is “Potemkin Village“. But at least the care is free – right? Added bonus: This is the system that our government is moving toward. Irish patient waits for 20 months to have surgery for correction of severe scoliosis then has surgery canceled at last minute because hospital had too many admissions the day before. But don’t worry, folks. She has insurance! Should patients who overdose on opioid pain medications receive future prescriptions for opioids? This study suggests that discontinuing opioids after an overdose results in a lower risk of repeated overdose. In a related article, the authors are “highly concerned” that 91% of patients in pain would continue to receive pain medications after an overdose. If doctors prescribe opiate pain medications after an overdose, we’re playing with patients’ lives. If we don’t prescribe opiate pain medications after an overdose, we’re heartless bastards who let patients suffer in pain. Either way, we get negative publicity. Another drive-by medical article. And you thought that the guy Martin Shkreli was a dick for hiking up the price on Daraprim. Wonder whether other pharma CEOs are going to get investigated for similar actions: Potentially life-saving drug Sovaldi that cures Hepatitis C costs $1000 per pill in the United States, but only costs $4 per pill in India. According to the article, drug companies gouge US citizens on prices of many medications. Advair is $150/month in the US, $10/month in India. Crestor is $86/month in the US and $3.60/month in India. Many cancer drugs cost several thousand dollars more per month in the US than they do in other countries. I know, I know. Shkreli was arrested on securities fraud, not for hiking the price of a potentially life-saving unique medication … like Sovaldi.

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