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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.

Interesting Emergency Department Complaints

Here are a few of the more memorable recent emergency department complaints. My mother has had early onset dementia for 40 years. We need to see what’s wrong before the end of the year. Patient arrived December 30. Hangnail on the finger for month. She pulled it off today at work and had to leave work because she saw blood. It was her typing hand. A patient was playing with her dog earlier in the day. She was laying on the ground and the dog jumped on her stomach. She has had severe back pain since this occurred and is out of pain medications. The dog was a chihuahua. Child was in the emergency department 2 days ago and diagnosed with a cold. Mother brought 4 other children in to be checked to see if they have colds. Constipation for 4 days. Had a bowel movement the day before he came to the emergency department, but didn’t have a ride to get to the hospital until now. Wants to know why he was constipated. Patient has had a BB lodged in his elbow for several years. Wants it taken out. “I just got that Obamacare insurance.” House was cold last night. Got chills. Wants to be checked. Lips are dry. I’m guessing that the responses to some of these complaints would be amusing as well ….

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Healthcare Update – 01-04-2016

Drug use (especially Ecstasy) at Australian music festivals has increased significantly over the past few years. One emergency department director noted that if people knew where the dealers had concealed the drugs to get into the festival, a lot of people would “nearly vomit.” I can tell you from experience that those places of concealment aren’t limited to music festivals, either. Patients gone wild. South Carolina belle Megan Whit drives pickup truck into a couple of telephone poles, then asks responding officers for drink of antifreeze. Proceeds to channel the Queen of Hearts from Alice in Wonderland and repeatedly yells “Off with your head!” at the officer. Taken to the emergency department where she insisted she was pregnant and that she overdosed on narcotics. Then shouted obscenities in the emergency department for several hours before testing showed she had used cocaine, crystal meth, and marijuana. This is your brain on drugs. Any questions? Welcome to Crazy Town. Well-written article about a day in the life of Indianapolis trauma surgeon Jamie Coleman. Many excellent pictures accompany the article. If you’re interested in medicine, this article is a must-read. Suppose one of your New Year’s resolutions is to stop drinking. What can you expect in the next 30 days? Here’s one person’s experience. Connecticut attorneys accused of misappropriating $4.3 million from malpractice client’s settlement and of failing to provide proof of more than $600,000 in legal expenses. Initial retainer agreement calculations would have resulted in fees of $2.66 million from the child’s $25 million settlement. Attorneys from Koskoff Koskoff & Bieder allegedly took $7 million in legal fees. Grievance committee investigating the matter finds “probable cause of professional misconduct” against attorneys in the case, but article notes that they were still allowed to keep all of the money. According to the Koskoff web site, Kathleen Nastri and James Horwitz represented the client during the trial. Employees snooping in the medical records of a patient who committed suicide. Co-workers accessing a patient’s medical records that were then used against him in divorce proceedings. HIPAA violations are “widespread throughout the VA” according to one whistleblower – who was put on administrative leave shortly after filing a complaint. This ProPublica investigation revealed more than 10,000 privacy violations by the VA system since 2011. The Office for Civil Rights cited the VA for more privacy violations than any other health provider in the nation, yet the VA has reportedly never been sanctioned for these violations. But if a patient suffering from a heart attack at a non-VA facility gets tPA at minute number 31, the doctor’s employment is on the line. Nice system we have, huh?

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What’s The Diagnosis 23

A patient presents with a rash to her back for the past 24 hours. It doesn’t itch, but it does burn at times. She hasn’t had the rash before. She had no fever. There were no new exposures to soaps, detergents, etc.  She was wearing no new clothing. She did begin bowling in her bowling league two days before the rash appeared. History of hypertension only. Taking lisinopril and aspirin daily. No other complaints. The distribution of the rash provides a clue to the diagnosis. What’s the diagnosis? How should the rash be treated? Scroll down past the pictures for the answer. . . . . . . . . . . . . . Answer: Hot Tub Folliculitis (Pseudomonas folliculitis) The final diagnosis was not shingles. This rash looks similar to shingles (zoster), but the lesions with shingles (and chicken pox) tend to be vesicles (filled with clear fluid) and not pustules (filled with white/yellow material). Also, shingles almost always involves only one side of the body and one strip of skin (a single “dermatome“). Before I asked the patient the question that led to the diagnosis, the rash seemed to be some type of contact dermatitis. It spared the middle of the back (along her spine) and it spared the area above her shoulders and below her waist. There was just a little bit of the rash on the front of her legs. So I started asking her. Are you *sure* you didn’t wear any new clothes in the past few days? A leotard maybe? New underwear? Go swimming and wear a new swimsuit? Remember how the patient just started her bowling league a couple of days before the rash began? Guess what she did after the game. She went and sat in one of her teammate’s hot tubs and drank beer. The nozzles from the hot tub were pointed right at her sides. This is a classic case of Hot Tub Folliculitis. Causative organism is pseudomonas aeruginosa. The rash is usually multiple painful red spots and some have pus in the center as shown in the last picture above. Treatment is generally … nothing. The rash goes away on its own in a few days to a week. Domeboro solution may soothe the rash. Some sources recommend dilute vinegar compresses to help speed healing. Oral antibiotics (usually fluoroquinolones like Cipro and Levaquin) generally don’t help much, but may be needed if the rash doesn’t resolve. More sites with information on Hot Tub Folliculitis include Wikipedia, WebMD, and About.com.

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Healthcare Update — 12-31-2015

How well are patients in one Norwegian emergency department having their pain managed? According to this study in the Scandinavian Journal of Trauma, Resuscitation & Emergency Medicine, not very well. Of patients with moderate to severe pain (58% of all study participants), only 14% received pain medications. The authors note that “Pain management is accepted as a quality indicator of care, and additional focus on strategies to improve pain management in the ED is necessary to ensure that all patients receive optimal pain assessment and treatment.” First of all, not all patients come to the emergency department with pain complaints. It gets idiotic when asking patients with a rash, a runny nose, or a cough about their level of pain. Second, the study required that anyone with a pain rating more than 3 of 10 be treated for pain. Demanding medication be given for 4 of 10 pain? Give me a break. Third if you want “strategies” to improve compliance, just take a page from the US playbook. Call pain the “fifth vital sign,” create some silly agency that monitors compliance and documentation of irrelevant metrics (you can call it NJCAHO), and create another agency to send out patient satisfaction surveys having little or nothing to do with assessing proper medical care. You’ll get 90+ percentile compliance guaranteed. Of course, then you’ll also create an incentive to prescribe an order of magnitude greater number of pain medication prescriptions, the number of deaths from drug overdoses will skyrocket, you’ll have to create a whole different system to monitor and track patients who become addicted to the pain medications and try to con doctors into writing prescriptions for more medications, other countries will make fun of your citizens for all the pain medications they use, the morale of the healthcare providers in your country will take a hit, and eventually fewer people will want to go into the healthcare profession. But the pain will be better controlled. Want to see what you’ll look like when you stick to that diet you’re beginning tomorrow for a New Year’s resolution? This web site will give you simulated before and after pictures. Unfortunately, it only has simulated females and it appears to be less accurate as the weight increases. But you can print up a picture to tape to your bathroom mirror to remind you of your goal each morning. Want some motivational quotes to paste under the before and after pictures? This Inc. article gives you 101 of them. Here are a couple of good exercise-related ones: The secret to getting ahead is getting started. No matter how slow you go, you’re still lapping everyone sitting on the couch. I’ve tweeted about this site before, but for those of you who missed it, if you need to get a full copy of a scientific article, but can’t afford the $30+ fee to download it, the site Sci-Hub will allow you to download full copies of research papers. Just paste the URL of the article into the site and it will provide you with a full copy of the article. It has 47 million articles in its library. Study in Gut magazine shows that taking proton pump inhibitors (“PPIs”) such as Protonix, Aciphex, Prevacid, Nexium, Prilosec, and Dexilant is associated with unfavorable changes the bacteria in the intestinal microbiome. These changes may explain increases in the rate of Clostridium difficile (“C. diff”) infections in PPI users. The study also notes that the changes in gut flora associated with PPI use are “more prominent than the effects of antibiotics.” Attack of the Glasshole 2.0 nears. Newest ...

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Unique Way Of Looking At It

“Doc, he’s been having some problems at home with his wife for the past few months. Took up drinking and now he’s been tipping the bottle on a daily basis.” Wasn’t exactly what we wanted to hear for a patient having chest pain. The patient’s story was concerning for heart disease and he had several cardiac risk factors, so after his initial labs came back normal (and after we excluded pancreatitis), he got admitted to telemetry for further evaluation. But it wasn’t quite that simple. When the floor nurses heard that he was a daily drinker for the past few months, they refused to accept the patient. Didn’t want him going into DTs on the floor, ya know. So he got put onto the DT pathway and sent to the stepdown unit. His initial CIWA score was elevated, so he got his first dose of Ativan in the emergency department. “What’s that for?” he asked. The nurse explained “It’s a pill that keeps your body from having alcohol withdrawal symptoms. It has effects on the brain similar to alcohol, but allows us to slowly lower the dose to keep you from having shakes or even seizures.” “Ah. I get it. A six pack in a pill, huh? I may need to get me some more of these.” “I’m sure you will, sir. I’m sure you will.”

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Healthcare Update 12-28-2015

A must-read opinion article by Theresa Brown in the New York Times. When health care reimbursement is predicated on documentation, documentation replaces the work being done. Charting is valued more than medical care. Teams of health professionals are hired not to provide medical care, but solely to evaluate the appropriateness of what other health professionals documented while trying to provide medical care. Many commonly-prescribed drugs being used in cocktails that result in overdose. One popular mix includes methadone, gabapentin, Klonopin, clonidine, and an over the counter allergy medication. During the first 6 months of 2014, of the 501 overdose deaths in Massachusetts, Fentanyl was present in 37% of overdose deaths while Klonopin and/or Xanax were present in 13% of overdose deaths. Gonorrhea becoming increasingly resistant to antibiotics. “Super gonorrhea” showing up in England. England’s chief medical officer Sally Davies warns that the sexually transmitted disease could soon become untreatable. Scary thought. Both parties in a non-monogamous relationship should take this age-old advice: “Don’t be silly, protect your Willie (or your Wilhemina).” Then again, Maryland apparently thinks that increasing taxes on alcohol will stop the spread of gonorrhea. When alcohol taxes in Maryland increased, gonorrhea rates decreased by 24%. The article concluded that “Alcohol tax increases may be an efficient strategy for reducing sexually transmitted infections.” For this to be true, the study must assume that a significant proportion of Maryland residents are sex-crazed inebriates. This is the classic “correlation” versus “causation” argument. Just because the sun rises when the cock crows doesn’t mean that the crowing causes the sun to rise. And we certainly couldn’t prevent the sun from rising by preventing the crowing. Then again, governments wouldn’t make any tax revenue by assaulting chickens. Good news for wart treatment: There is a therapy more effective than expensive visits to the dermatologist for liquid nitrogen cryotherapy. Bad news is that you have to walk around with duct tape stuck to your wart for six weeks. That’s right … duct tape treatment was effective in removing warts in 85% of cases while traditional freezing was effective in only 60% of cases. The study was from 2000-2001 and had only 61 patients, but it’s worth a try. Oh, and if you want to know how to get your Willie unstuck from inside a PVC pipe, there was an article in the “related content” for that as well. Think blowtorch. I actually had to click off of the site because the articles in “related content” kept piquing my interest. Patients gone wild. Ohio’s own Cynthia Squire arrested for “verbal onslaught” against hospital staff and Port Clinton police officers tried to calm her down in Magruder Hospital emergency department. Ms. Squire threatened to kill her boyfriend and her daughter’s boyfriend and called “everyone around her vulgar names.” In other news, Port Clinton police then responded to another call and arrested several reindeer for disorderly conduct after their interactions with an unnamed reindeer with a red nose. Infants and toddlers being prescribed strong antipsychotics such as Risperdal? I’m a little leery about this idea.

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