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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.

The Drowning

By Birdstrike MD   “You want them to see you, like they see any other girl” -Against Me!   I head to work at my new locums job on the California coast. Summer 2015 is going to be a great one, I think to myself. I make the turn into the hospital parking lot and a rusty old Trans Am cuts me off. I slam on the brakes to the soundtrack of screeching tires. Geez, I think to myself. It’s my first day at this job and they’re already trying to kill me. I drive on, and I pull into my parking space. My headache is starting a little too early for this shift, I think to myself. The sun is out, the sand is hot, and it seems like everyone must be at the beach but me.  The humid heat is as thick and soothing as suntan oil.  I leave it and walk into the cold and clinical hospital. Out of the EMS radio and through the air crackles, “ELDERLY FEMALE CARDIAC ARREST…DROWNING…INTUBATED…NO PULSE…45 MINUTE DOWN TIME…ETA 5 MINUTES.” Jane the nurse looks at me.  “This one’s yours,” she says with a wink. “You got it,” I answer. Way to start off with tragic one, I think to myself and take a deep breathe, shaking my head. “Boom” goes the grinding, mechanical sound of the automatic doors as EMS rolls the stretcher into my ER. In they wheel my patient, while feverishly sweating and performing CPR and bagging air in and out of the patient, one breath at a time. With my back against the wall, they wheel the head of the bed up to me. I see a large, elderly female, dressed in a bright orange one-piece women’s bathing suit. I grab my laryngoscope and look to make sure the ET tube is in the airway. Her face is bloated and purplish-pale except for the mess of pink lipstick smeared around her mouth, likely from EMS attempts at placing the tube. I check the tube and it’s okay. “45 minutes with no pulse at any time? Drowning?” I ask EMS. “Yes sir,” responds one of the burly EMS guys. “We got the tube in right away, started CPR, gave epi per protocol, and…..nothing.” “Did you see any of her family?” I ask. “No family. She was with a big church group at the beach for a picnic, with a bunch of kids. Youth group, or something,” says the EMT. “What?! Doc. Look!….” says Nurse Jane who had just cut off the patient’s bathing suit, pointing at the patient’s groin. There, no longer covered by the woman’s bathing suit, is a penis and testicles. I look at Jane, I look at the two EMTs, and they look at me. “I’m just as confused as you doc,” says the EMT, looking at me wide eyed as he raises his hands. “What’s the patient’s name again?” I ask. “Let’s make sure we have the correct patient and correct name.” “We’ve got a driver’s license and the picture matches. Pat ——, female, is what’s on the ID,” says the EMT. “So, the friends that are here, know, or don’t know? Help me out here.” “I have no idea, doc. Her friend, who looked like a little old church lady, referred to her as ‘she.’ That all I know,” answers the EMT. “Okay, thanks. Regardless, we have no pulse, over 45 minutes of downtime and zero chance of survival with a warm water drowning. Time for me to call the code and notify the family. Time of death 17:01.” CPR stops. I’ve declared the ...

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Schadenfreude: Florida Leads The US In Primary Care Physician Shortages

I can’t help my feelings of schadenfreude when I happened to see a graph at the Kaiser Family Foundation noting that Florida has the largest shortage of primary care physicians in the United States. Only 42% of Florida’s overall need for primary care physicians has been met. Runner up California was a distant second. Why do I continue to get satisfaction from Florida’s troubles? It goes to show that states reap what they sow when they create policies to attack medical providers. When Florida’s Senator Bill Nelson whines that Florida “desperately needs more doctors“, maybe he should discuss with Governor Rick Scott why Florida has chosen to implement so many unfriendly policies toward physicians. I’ve been keeping a separate page with some of the reasons why physicians should avoid going to Florida to practice medicine. Here are a few reasons: Florida voters changed the Florida Constitution so that if a physician loses three malpractice cases, the physician’s license is automatically revoked. Florida used to cap non-economic damages in malpractice cases. Not any more. Florida’s Supreme Court recently struck them down (.pdf file). News article from the Tampa Bay Times here. Florida voters also created a Constitutional Amendment that makes peer-review documents related to adverse events discoverable in lawsuits. Florida is perennially on the list of Judicial Hellholes. When medical providers begin searching for the best places and worst places to practice medicine, Florida definitely is one of the worst. Don’t practice medicine in Florida.

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Healthcare Update — 05-27-2015

Patient in Ontario Canada’s Guelph General Hospital emergency department has “interaction” with two police officers, both officers whip out their guns and shoot the patient dead. No further information available. Kentucky newspaper reminds everyone that stroke is an emergency and requires immediate care. Anyone having signs of a stroke should immediately contact Dr. Louis Caplan at Beth Israel Deaconess Medical Center. Don’t waste your time in “dangerous” emergency departments. I wasn’t being serious about contacting Louis Caplan. If you have signs of a stroke, go to your nearest emergency department. We’ll get you the help you need regardless of what some ivory tower neurologists think. Maryland patient in “horrible pain” calls ambulance. As paramedics “rushed her away,” her husband tucked her purse under her arm. She had her purse in her clutches until she reportedly had a “cardiac arrest” and went unconscious in the emergency department. She woke up the next day on a ventilator and the $1,100 that was in her purse was gone. I sympathize with the woman for losing her money, but something just doesn’t smell right about this story. Crystal meth is bad. In fact my uncle knows a guy whose cousin was on meth, gouged his eyes out, and ate his eyeballs like little hors doeuvres. Unfortunately, this story, told by an Australian member of parliament, was not able to be verified. That didn’t keep news agencies from picking up the story and running with it. Anything for the clicks. Nearly a year after the VA scandal was made public and what’s happened to the people responsible for the fraud? One person was fired, a few others were “disciplined” with paid leave and transfers. In addition, the number of patients waiting longer than 90 days to receive medical care has nearly doubled. This is the system we’re hoping to implement on a widespread basis? Here we go again with the antibiotics for appendicitis debate. According to several small studies in Europe, antibiotics can cure about 70% of patients with acute appendicitis. This article also states that most people who develop a ruptured appendix do so before they get to the hospital. And – because American sailors who were on submarines for six month stints did well when given antibiotics for appendicitis, obviously antibiotics should be a good treatment. The problem with this logic is that submarines didn’t have CT scanners to prove that patients actually had appendicitis. This just means that everyone who had a belly ache got antibiotics. We don’t know if any of the sailors actually had an inflamed appendix. In addition, even if antibiotics did cure appendicitis, who’s going to want to run to the hospital for repeat ED visits and CT scans every time they get lower abdominal pain? Remove the inflamed appendix and be done with it. Rise of the machines. iControl-RP is a machine that monitors brain wave activity, pulse ox and vital signs during surgery and adjusts the dose of anesthetic accordingly. A professor once told me that anesthesia is a boring specialty … about 95% of the time. The other 5% it is life or death. Not sure how a machine would respond in one of the 5% situations. Despite this, the machine’s co-developer is “convinced the machine can do better than human anesthesiologists.” Wonder how its intubation skills are … Pedialyte is advertising itself as a cure for hangovers. Probably because kids won’t drink it. Take a sip some day and you’ll see why. The stuff tastes horrible. The company touts the increased sodium and potassium concentrations in Pedialyte versus Gatorade as the reason it reportedly ...

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Body Blow

A patient came in semi-conscious with low blood pressure. She was known to paramedics for her history of opiate abuse. In the past, the patient had been treated several times for adverse effects from excessive doses of prescription pain medications. The nurses were having trouble trying to start an IV and there were no good veins visible, so I grabbed an IV, put a tourniquet around the patient’s arm, and slapped the back of the patient’s hand several times to get the veins to stand out. It worked. I was able to get an IV in on the first stick and the patient received some Narcan which immediately woke her up and brought her blood pressure back to normal. Then she demanded to see a hospital administrator. “That doctor hit me.” “Wait. Whoa. What??” “He hit me in my arm, then he hit me in the side of my head.” “Ma’am, I slapped the back of your hand so I could start an IV, but no one was near the head of your bed.” “No … You. HIT. Me.” Another patient was in the room next to hers waiting to have a laceration sutured. The curtain had been pulled back so that everyone could access the patient’s bed and the patient had watched the entire event. “You’re lying. He didn’t touch you.” The patient said. “You mind your business,” said the resuscitated patient. “I WANT to talk to an administrator.” So the administrator came to the emergency department and took statements from everyone. He promised the patient that he would follow up on the matter and he left the room without even talking to me. A little while later, I went and sewed up the laceration on the other patient’s face. “You’ll be able to resume your modeling career in no time,” I said with a smile. “Sorry you had to wait.” “Hey. At least you didn’t hit me,” he said with a wink. “Yeah, well you haven’t been discharged yet,” I joked back. Shortly after we had discharged the patient, the overdose patient rang her call light and demanded to see an administrator again. The administrator came back to the emergency department and spoke to the patient. A nurse overheard him promising to follow up on both matters. But what happened? No one had been in her room between then and the first complaint. Turns out that the patient told the administrator that I had also threatened to hit another patient. I’m wondering if the administrator can investigate someone being run over by a truck after they leave hospital property …

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This Is All YOUR Fault

When a patient comes to the emergency department at 3:30 in the morning with an injury that was sustained while moving furniture just prior to arrival, it raises my eyebrows a little. When the first two sentences out of the patient’s mouth to the triage nurse are “I need something for pain – it’s 10 out of 10” and “Also, I’m allergic to Toradol, tramadol, codeine, morphine, and I can’t take NSAIDs because I have an ulcer” then it raises my eyebrows even more. The injury wasn’t a 10 out of 10 injury. The patient was reportedly moving a couch while wearing flip flops. She caught her foot and hit the outer part of her great toe on the edge of the couch. In the process, she ripped the callus off the side of her great toe, leaving a raw area about an inch in diameter and a scrape to her instep. This injury caused her to have 10 of 10 pain. As the nurse started to clean her wound, the patient howled. Literally. “Aren’t you going to give me anything for this pain?” “How about we start with some Tylenol.” “Tylenol?!?!” “You’re allergic to all of these other medications and your wound certainly doesn’t look bad enough for something like Norco. So I think we’ll start with some Tylenol.” She looked at her boyfriend who had accompanied her to the emergency department. “You know, it’s FAKERS like you who make it so that people in legitimate pain like me don’t get proper pain medicine.” He had a shocked look on his face. I didn’t know the boyfriend, but I kind of agreed with the patient’s sentiments. Drug seeking patients do tend to ruin things for patients who really are in pain. This woman appeared to be overacting from the pain she was having from her injury, but who knows? It wasn’t too busy in the ED at the time, so I went and looked the patient up on the state controlled substances database. Surprisingly, the patient only had 88 prescriptions for controlled substances from 18 different prescribers in the past 12 months. Only four prescriptions for Norco in the past 10 days. I went back in the room and handed her the printout from the state database. She scowled at her boyfriend. “This is all YOUR fault.” Then she got up and stomped out of the emergency department before the nurse had a chance to bandage her wound or to provide her with Tylenol for her 10 out of 10 pain. Funny how information can have such a dramatic effect on relieving pain.  

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Louis Caplan, Maureen Dowd, and Lack of Professional Ethics

With the flurry of Twitter posts about Maureen Dowd’s article “Stroke of Fate” in the New York Times, it almost seems as if the subject is already stale. Maureen Dowd is the Pulitzer prize-winning op-ed columnist for the New York Times who tells a compelling story about a young patient who suffered from a stroke. The patient was a healthy triathlete and she initially attributed the symptoms of her stroke to a migraine headache. Ms. Dowd’s article also touched upon the frustration and fear that patients feel after the diagnosis of a stroke which was an important part of the article. However, somewhere in the middle of the article, Ms. Dowd does a journalistic faceplant that probably had Joseph Pulitzer doing a few backflips in his grave. Ms. Dowd accompanied the subject of her story – her niece – to Boston in order to be evaluated by a national stroke expert. There they met 78-year-old Dr. Louis Caplan, a Harvard professor of neurology. Dr. Caplan made several inflammatory quotes regarding emergency departments which Ms. Dowd was only too happy to publish. She doesn’t appear to have fact checked the statements, she doesn’t appear to have asked the professor for the basis behind his statements, nor does she appear to have asked other experts in the field for their comments on the topic. Of course, Ms. Dowd may argue that her failure to check her sources was an innocent mistake or that was part of her journalistic expression, but in either case, she was irresponsible and unethical. She used one of the largest forums in the United States to provide misinformation about emergency medical care. As I read through Dr. Caplan’s quotes and the comments to the article, I can’t help but wonder whether or not Ms. Dowd’s actions were intentional. It doesn’t take much insight to realize that comments from a medical “expert” who denigrated another medical specialty would result in an avalanche of clicks to the New York Times web site. The problem is, Ms. Dowd, your article generated interest not because it was good journalism, but rather because it was hack reporting. You could have used your niece’s misfortune to provide information to your readers about the signs and symptoms of vertebral artery dissection, the treatment, and the outcomes. Instead you threw your integrity out the window to create just another piece of clickbait. Shame on you. It isn’t just Ms. Dowd who failed at the New York Times. The New York Times editors failed. Again. Ms. Dowd’s article is eerily similar to a sepsis article written by Jim Dwyer in the New York Times several years ago. Mr. Dwyer told the story of his nephew, Rory Staunton, who, in the midst of influenza season, went to the emergency department with fever and vomiting. Rory received treatment in the emergency department, his symptoms improved, and he was discharged, but he later died from sepsis. Mr. Dwyer went on a crusade against the hospital and the emergency medical providers. In the process, Mr. Dwyer failed to note many of the circumstances regarding Rory’s care, made many inappropriate comments, misapplied sepsis guidelines that were not designed for children, and then tried to hide the fact that those guidelines were not designed for use in children. When called out on his selective reporting of the facts, Mr. Dwyer made excuses such as Rory may have been a child, but he “was the size of an adult.” That episode of drive-by journalism didn’t work so well, either. So the New York Times editors allowed yet another poorly researched and inflammatory article to be published in ...

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