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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.

Blaming doctors for prescription drug abuse

An article written by two physicians in Time magazine questions whether we should blame doctors for the large number of chronic pain patients and the abuse of prescription pain medications. There are two frames of reference to this article. First, no one can argue that prescriptions for pain medications in this country are excessive. The article notes that in 2011, “enough hydrocodone was prescribed to medicate every American around the clock for a month.” As both authors are emergency physicians, the end of their article notes that “we must stop fearing patient-satisfaction surveys and talk honestly to our patients about pain.” Ask most emergency physicians and they will tell you that satisfaction surveys pressure physicians to overprescribe multiple medications, including antibiotics and opiates. But where do all the medications go? Note how many commenters to the article are upset because they or their family members are having a difficult time obtaining pain medications for their chronic medical problems. Doctors are becoming increasingly aware that if they prescribe pain medications to a patient who dies, there’s a decent chance they’ll be dragged through administrative and legal proceedings regarding the death. So doctors then learn to fear the bad outcome and then take steps to avoid the bad outcome. Doctors can’t get sued if they don’t prescribe the pain medications. Patients in legitimate chronic pain are paying the price – and it isn’t just in the emergency department, either. From the comments: “their physician won’t see them anymore because they need stronger pain medication” “His GP won’t prescribe, his GI won’t prescribe, the Pain Clinic keeps trying to push him into treatments that DO NOT WORK for his disease” “the ER staff will still stand around and pretend like opioids don’t exist and it’s okay to let the patient lay there in pain” Reminds me of a post I wrote nearly 5 years ago. Only this time, the solutions that our governments are proposing seem to be adding to the problem. When we vilify, sue, and criminalize doctors whose patients die from medication overdoses, fewer and fewer doctors are going to be willing to prescribe pain medications. I’m predicting that we’re going to see a downward trend in the amount of pain medications prescribed. The threat of incarceration is going to outweigh the threat of bad satisfaction scores. And we’ll all be “safer” through more regulations, bad press, and blaming physicians for the bad apples … right?

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Should AEDs be required?

Interesting question posed in a California court case. There’s that state acting up again. In Verdugo v. Target Corp (.pdf file) a 49 year old woman collapsed in a Target store. Paramedics were called, but it took them several minutes to arrive and several more minutes for them to find the patient. They were unable to resuscitate her and she died. The family sued Target for failing to have an automatic external defibrillator (“AED”) in its store, apparently alleging that their mother would (might?) have been saved had an AED been available (there are those thingees called “damages” again, Matt). In its opinion, the US Court of Appeals noted that “defibrillation is the only definitive treatment for cardiac arrest.” That isn’t true. Defibrillation only works on the patients who have ventricular fibrillation or pulseless ventricular tachycardia as the cause of their cardiac arrest. Defibrillation does not work on asystole, PEA, or agonal rhythms. While there may be an increase in survival to admission rates when care is received sooner, there was no statistical difference in survival to discharge rates in some studies, while other studies did show an improvement in survival to discharge. Also note that in this study, the number of patients with out of hospital cardiac arrest who were in asystole (and who therefore would not benefit from an AED) was between 72 and 84%. Now the California Supreme Court will decide whether every commercial business should be required by law to have an AED on premises. This case troubles me. If we start down the path that an AED must be available at every business, then it becomes a “slippery slope” argument. How close do the AEDs have to be? If a building has multiple floors, does there have to be an AED on every floor? For large businesses, how close do the AEDs have to be to each other? What about shopping malls? Will every store in the mall be required to purchase one? Even the kiosks? What will be the requirements for maintaining them? How many people will need to be trained how to use them? It isn’t just about the AEDs, either. What other medical care will be required the next time someone dies from low blood sugar, an allergic reaction, or a choking episode. What about for people who fall and could die from a head injury? On site CT scanners and drill bits to relieve deadly subdural hematomas? Where would the requirements for medical care to business invitees logically stop? I’m having a difficult time coming up with a rule that requires AEDs but that doesn’t require additional medical equipment and training of employees. And if the laws require that business owners afford special medical care to business invitees, wouldn’t invitees to one’s home – to attend a party, for example – fall under the same legal rule? Another example of fearing the bad outcome. Say – if California rules that AEDs are required, anyone want to join in funding a startup AED manufacturing company? There will suddenly be a lot of AEDs that need to be purchased. Hat tip to Walter Olson at Overlawyered.com

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A Physician Tries to Make Sense of Sandy Hook

By Birdstrike M.D.   Since the massacre of innocent school children and those that gave their lives educating and trying to protect them this past Friday at Newtown Connecticut’s Sandy Hook Elementary School, I’ve struggled to make sense of this calamity as much as much as anyone.  As a Physician who has worked to save the lives of sick and injured children, and as a father of children the same age as those massacred in cold blood, I have searched for answers to the questions, “Why?”   “How do we make sure this never happens again?” and “How do I know this won’t happen to my family?”  along with everyone else.  As I’ve read, seen and listened to various explanations and solutions, some better than others, most have rung very hollow.  The arguments and blame fly back and forth, “We need to ban guns,” “We need more guns,” “We need more outpatient mental health treatment,” “We need to re-institutionalize the mentally ill,” and so on.  The more I listen, the less I am convinced that anyone I’ve heard, from the checkout clerk at my local grocery store, to the President of the United States has any real solution to prevent this from happening again, or even make such happenings less frequent. As I dropped my daughter off at school today, and let her get out of the car and walk away from me and out of my sight, I realized that to a certain extent, this was and always has been an act of faith of sorts.  As I’ve thought more and more about this horrible incident, the questions keep coming, but without answers.  I have no good answers to the above questions.  In a nearly post-spiritual world where technology can do practically everything but find answers to the truly important questions in life, I realize there is a word that does perfectly describe this incident, and consolidates all the pain, hurt, chaos, insanity, confusion, murder, blood and tears.  All religion, preaching, atheism, agnosticism and separation of church-and-state arguments aside, the only word I can find that offers any sort of explanation, summary or satisfying consolidation of what we saw last Friday is…..evil. Pure evil. If anyone doubts the existence of true evil, you’ve seen it.  That is the most disturbing and frightening thing about the incident at Newtown’s Sandy Hook Elementary School.  Despite all the good in this world and all the good we may try to achieve with varying levels of success as physicians trying to heal sick and injured children, or trying to protect our own children, we share this world with a certain element of pure unadulterated evil.  Despite all of our necessary efforts to prevent, protect against and deter it, when someone chooses to truly commit an act of pure evil, they can.  When one does so, there is very little any of us can do about it but hurt, mourn the lost, support the living and move forward with acts of good hoping time will offer at the very least, some solace and clarity.  My deepest condolences go out to the victims of this incident, their families and all of those touched in any way.

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Healthcare Update — 12-17-2012

Man faces 6 to 30 years in prison after being convicted of aggravated battery for stabbing emergency physician in chest with steak knife. During trial, patient stated “If they’d followed emergency room protocol, we wouldn’t be here right now.” We do it to the heart … why not to the brain? Stents may help certain stroke patients. Why we need to dump the FDA. +1. Cute … or scary. In the Christmas spirit, Loyola Medical Center comes up with the Twelve Days of Trauma and how much trauma care costs.

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Open Mic Weekend

OK, so I didn’t get home until late yesterday, so it’s only a half-weekend. So between shopping trips, you can still post any medically-related comments, questions, or observations in the comments section. I’ll try to answer any questions on Monday or Tuesday. As usual, the only rules for comments are that there are no personal attacks and that the comments/questions have to be medically-related. Have a safe and enjoyable weekend. Only 9 shopping days until Christmas, you know.

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Healthcare Update — 12-10-2012

You know the ED? No. The OTHER ED. Yeah. That. The one that you get, not the one that you go to. Well it turns out that researchers did a study comparing men with chronic periodontitis to men without chronic periodontitis and they found that men who had chronic periodontitis were more than 3 times as likely to have ED as were those without chronic periodontitis. Remember, this is only a correlation. There could be lots of intervening factors that I’m just going to leave alone right now. It would be interesting if the study included those who wear dentures, also. In that way they could determine whether the presence of teeth or the presence of bacteria were more likely to account for the findings. That stuff running from your nose every time you bend over may not be boogers … it could be spinal fluid. Amazing University of Arizona surgeons cured this problem with minimally invasive surgery rather than cutting into the patient’s skull. A medicine “visionary’s” view of seven things that allegedly frighten physicians about Obamacare. I disagree with several of them and others were occurring long before Obamacare was concocted. By the way, doc, the number “6” comes between 5 and 7. If there’s one thing I can’t stand about people who can’t count, it’s that they don’t pay attention to detail and they confuse their readers. When the cure is worse than the disease … fighting bedbugs. Several people dying from pesticide overdose – although using 18 foggers in your home over a two day period probably exceeds the manufacturer recommendations. Maybe some brainiac DA will file murder charges against the owner of the store who sold the woman all the insecticide. That’s about how bizarre things are getting in this world lately. Great. Now I’m itching.

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