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Healthcare Updates

Links and commentary to healthcare news around the internet

Healthcare Update – 05-07-2013

Also see more Healthcare Updates on my other blog at EP Monthly.com Here’s a headline bound to catch your attention. Psychiatrists spend a million hours a year attempting to get approval from insurance companies to admit suicidal or mentally ill patients. Link to the study in Annals of Emergency Medicine is here. Study on Medicaid use in Oregon shows that patients who have Medicaid have no better health outcomes than people who don’t, but they do utilize “a lot more health care.” In addition, Medicaid “nearly eliminated catastrophic out-of-pocket medical expenditures.” Is Obama just dangerously misinformed about ObamaCare? Or is he willfully misleading the country? Article picks apart statements that the president is making about the UnAffordable Care Act. The rules about the UnAffordable Care Act keep evolving. Wellness programs that require workers to meet certain health standards to get lower insurance premiums cannot be included as part of minimum coverage requirements that employers must meet. Unions lobbied against wellness programs alleging that they would discriminate against unhealthy workers. South Carolina legislature flips ObamaCare the bird. State House passed a bill that makes it a criminal act to enforce or attempt to enforce the law in South Carolina. Governor Nikki Haley calls the health care exchanges “nothing more than a way to make the state do the federal government’s bidding in spending massive amounts of taxpayer dollars on insurance subsidies that we can’t afford.” Ouch. More allegations of “false advertising” relating to advertised emergency department wait times. This case is at St. Elizabeth’s Hospital in Brighton, Massachusetts. The hospital spokesperson says that the advertised time is a “door to room” time which is a “standard measure” for hospital emergency departments. Not true. False advertising and consumer fraud claims aren’t subject to the medical malpractice caps that are present in many states. Will be interesting to see where this is headed. Man’s runny nose that lasted for several years wasn’t an allergy — it was a CSF leak. And don’t go running to the ED asking for MRIs of your brain because your nose is running. This was an exceptional case. Senator Chuck Schumer wants to increase federal restrictions on hydrocodone prescriptions because they are “gateway drugs” and because “our doctors are prescribing too much of this.” Hey Chucky … how about we put federal restrictions on how many dumb laws you can try to pass? After all, those laws are a gateway to … oh I don’t know … even dumber laws? Patients gone wild. Florida patient attacks doctor after being told to stop cursing and to stop calling the staff names. Arrested and faces felony charges. More patients gone wild. New Jersey man arrested for disorderly conduct and criminal mischief in St. Luke’s Hospital emergency department. No mention of what he did to deserve such charges. JAMA study shows that children with migraine headaches were six times more likely to have experienced colic as an infant. Meanwhile, a study published earlier this year in Pediatrics showed that colicky infants often had significantly different intestinal flora than their non-colicky counterparts. Proteobacteria was increased in colicky babies while bifidobacteria and lactobacilli were decreased. More articles on doctor shopping and drug seeking patients. This Ohio article provides a couple of chilling statistics from a study done Toledo’s St. Lukes Hospital: Ohio overdose deaths totaled more than traffic fatalities by almost a third. And of the 1,544 Ohio citizens who died of drug overdoses in 2010, prescription opioids were listed on 45% of the death certificates. Defense attorney praises doctor for refusing to settle a medical malpractice case when sued for a patient ...

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Healthcare Update — 05-01-2013

Doing a mini-update for now. More to come. Woman walks into hospital, goes to random patient rooms and tries to pry open machines infusing pain medication into IV lines. When that doesn’t work, she cuts the IV lines and steals the medications directly from the IV lines. Listen, lady. Hospitals are probably one of the more video camera-laden places in our society. Walking through a hospital will virtually guarantee that hospital security will have a picture of you … which they will then post on the news wire. Like this. Easier method: Go to Nurse K’s hospital emergency department, ask for Dr. FeelGood, and complain of bad back pain. Taking patients gone wild to a new level. Australian nurse has part of her breast bitten off during altercation with patient. Concern grows over the “rising tide of violence in the emergency department.” Well, if I’m going back to go to the Greybar Motel after my layover in the emergency department, I may as well try the ol’ bathroom escape trick. Tennessee inmate escapes from emergency department bathroom after getting a bathroom break. Caught shortly afterwards and is now charged with felony escape in addition to his other felonies. Pennsylvania’s Dr. Robert Childs bashes emergency department in letter of resignation to hospital. Criticizes emergency physicians for transferring a 7 month old with a burn to the hand to a burn center – where the patient was admitted for three days. States that he could have treated the infant’s burn by applying cream and bandages which would have cost about $150 and would have saved the family from traveling back and forth to the burn center. Those mean emergency physicians don’t trust doctors in our area so they ship them out of town. Oh, and they call and wake him up in bed at night, too. Bwaaaaaahhh. Hey, Doc … the criteria for transfer of burn patients (.pdf) include both burns involving the hands and burns in hospitals without personnel qualified for the care of children. When burns to the infant’s hand that you treat for $150 scar down and cause loss of function in the fingers, I’m sure the child and the family will be so pleased that you decided to save them money and drive time. You need to go read a book or two and pipe down with your silly letter writing. Then you can apologize to the doctors you bashed. From a reader … Here’s one for your long-suffering “bambulance driver” readers… “According to the incident report, Ferguson said she didn’t have a car and this was the only way she had to get around and Medicaid paid for it anyway. It was part of her benefits. “And all of those ambulance trips taken by Ferguson? “Each one costs $425, plus mileage. “Officials say what Medicaid doesn’t pay, taxpayers will have foot the rest of the bill, more than $400,000.” N.B.  She’s 51 and on Medicare, has been doing this for seven years (since she was 44), and thinks using ambulances for basic transport should have been part of the “benefits” she was “entitled to”.  We’re stuffed. Until providers and police prosecute thieves like this, I agree. We are stuffed. If this lady made hundreds of false police reports to get a ride to the police station or stole hundreds of FBI vehicles to take a drive downtown, she’d be in the Greybar Motel quicker than she could say “abdominal pain.” And think about the access to ambulance services that people with true emergencies lost while paramedics were playing Driving Miss Daisy with this woman. From another reader ...

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Health and the Human Microbiome

I’m personally a strong believer that the interaction between our diets and our mircobiome affects our health in more ways than we realize. I think we are just starting to scratch the surface of the ways in which our microbiome keeps us well. Given that, I found a couple of recent medical studies quite interesting. First was a fascinating correlation between diet and heart disease. Presence of trimethylamine N-oxide or TMAO is a strong predictor of arterial placque accumulation in patients. Arterial placque rupture is what causes heart attacks and some strokes. TMAO levels are increased in patients who ingest carnitine – which is abundant in red meat … and energy drinks (where the ingredient is listed as “L-carnitine”). The part of the study that I found most interesting was that people who didn’t eat a diet high in red meats – vegetarians, for example – did not  produce TMAO when fed a high-carnitine diet. Researchers also found that mice which were given broad spectrum antibiotics to wipe out their intestinal flora did not produce TMAO when fed a high-carnitine diet, either. In other words, the composition of the intestinal flora within the human gut seems to affect ones ability to produce TMAO. The study didn’t prove causation, but a diet high in red meats and/or energy drinks is correlated with elevated TMAO levels. The hypothesis that still needs to be studied is whether a high-carnitine diet encourages the growth of flora that converts carnitine to TMAO – or whether it may inhibit growth of some intestinal flora that stop the conversion. A link to the actual study article is here. Similar data was published 2 years ago, so it isn’t exactly a novel concept, but I still find it fascinating. Another study showed the relationship between weight loss and gut flora Gastric bypass surgery causes weight loss. Initially, it was believed that the bypass itself caused the weight loss. These researchers took gut flora from mice who had undergone a gastric bypass procedure and implanted them into mice that had no surgery. The transfer of bacteria alone caused weight loss and decreased fat mass in the mice who never had the bypass surgery. Still another diet/health study showed a correlation between intake of fruits and decreases in hot flashes during menopause. More fruit, vegetables, pasta and red wine – similar to a “Medirerranean-style” diet – was correlated with a decrease in the incidence of hot flashes and night sweats by 20% during menopause. When I read stories like these, I always start thinking about “causation” instead of correlation. For example, in this case does a Mediterranean-style diet cause growth of bacteria that inhibit hot flashes and night sweats? If so, do other diseases that cause night sweats (say lymphoma or tuberculosis) affect the same bacteria? And if so, could changing the bacterial flora in the gut affect those diseases? I know. I know. Disengage the clutch, WhiteCoat. You’re thinking too hard. Then again, I remember when I was a medical student and our highly esteemed professors taught us that most ulcers were caused by “stress” and “Type A personalities” — until Helicobacter pylori was discovered.

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Healthcare Update — 04-23-2013

Also see more Healthcare Updates on my other blog at EP Monthly.com New York family wins $130 million in medical malpractice lawsuit stemming from obstetrical negligence case where patient was born with cerebral palsy. The back story to the verdict is even more wild. The plaintiffs rejected an $8 million settlement offer, then lost the case at trial. An appellate court reversed the verdict and the case was tried a second time, resulting in a hung jury. The third trial resulted in the $130 million verdict. Georgia hospital gives up fight to erect a freestanding emergency department. State denies request because the area “already has plenty of emergency services and that the proposals failed to demonstrate the need for new services”. Ever wonder why the state only controls hospital construction? Why doesn’t the state say that areas already have plenty of strip malls or Burger Kings or banks and deny building permits to those businesses? Hospital in Nevada accused of “patient dumping” by giving psychiatric patients one-way bus tickets to California. The article doesn’t say whether the patients are prematurely discharged from the Nevada hospital before being sent to California, but if not, California officials are certainly stretching the definition of “patient dumping”. Ohio man found intoxicated and cursing in Kettering Medical Center ED. Taken outside by police and wants bus ride back to VA. Good thing this wasn’t California or the police would have been accused of patient dumping for bringing him there. Couldn’t resist clicking on the link after reading the headline. Seven Things Teenagers Can Do To Stay Out of the Emergency Room. Ultimately the advice, such as avoiding guns, avoiding drugs, and regularly exercising, is common sense … but then again, if some teenagers used common sense they wouldn’t end up in the emergency department, so the advice is worth repeating. Patients gone wild. Perhaps more appropriately patient families gone wild. Stabbing victim brought to ED in Albany, GA, then victim’s family attacks stabber. A doctor and several nurses were pushed in the melee by a friend of the victim, apparently for “taking their time” when the perpetrator, one Quantavious Thomas, wasn’t sure whether or not his friend was still alive. “Ever hurt anyone?” It’s like a story line from that canceled Fox TV series Mob Doctor. Cleveland Clinic emergency nurse tries to hire an emergency room patient to kill someone over a property dispute. Now the nurse will be wearing striped scrub suit in the Greybar Motel. Does a charge of $2500 for a five mile ambulance ride and $1900 for a “60 second” emergency department visit demonstrate a need for universal health care? I don’t think so. Changing the payor won’t necessarily decrease the charges. Another thing I found interesting with the article was the number of commenters who weren’t as concerned with the charges as they were with making sure that someone else was paying for them. Eventually that “someone else” trickles back to all of us. Expanding liability for medical malpractice. A cancer patient was moved to a long-term care hospital where the patient was made a DNR without the patient or his wife agreeing to DNR status, then was started on “comfort care” measures and allegedly died from an overdose of pain killers. An autopsy listed the patient’s death as an overdose and listed the manner as an “accident.” If plantiffs can show that the hospital’s actions were “willful, reckless, or a felony,” then New Jersey’s medical malpractice caps on non-economic damages don’t apply. I’m torn on this case. On one hand, do we want the Liverpool Pathway to be instituted in ...

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Refusing Number 12

A 16 year old patient came with her mother to the emergency department for another “kidney stone.” She was having lower abdominal cramping – mostly on the left – which had been present for the prior two days. The pain was dull and was worse when she urinated. She was sure this was a kidney stone because it was just like the twenty or so kidney stones that she had in the past. “Wait a minute. Did you say ‘twenty’?” “Yeah. Twenty.” I immediately started asking about whether the patient had been worked up determine why she kept having kidney stones. She had been diagnosed with hypercalcuria – high calcium levels in the urine. When the levels of calcium are high in the urine, then calcium is more likely to precipitate out and create stones. Her calcium levels were chronically high and her pediatric urologist couldn’t figure out why. And she was in a lot of pain from these kidney stones. I ordered a few labs, some Motrin and some IV fluid, then went to look through her old medical records.  “Radiographic studies” tab showed 11 CT scans of the abdomen and pelvis plus at least a dozen ultrasounds over the prior 6 years – and that was just in our facility. Multiple different physicians, including family practitioners, urologists, and emergency physicians had ordered the different tests. On one of the CT scans about a year ago, there were multiple small calcifications in both kidneys. “Laboratory” tab showed 27 metabolic panels – each one with a normal calcium level. There were also six urine calcium levels – each normal or below normal. I printed out the labs and showed them to the mother. “Well her abnormal lab tests were at other hospitals.” “Which other hospitals? I want to get copies for our records.” “There have been quite a few.” “You can just give me a couple, then.” [ awkward pause ] Then the daughter interrupts. “It’s OK mom. I feel better now.” And so the patient and her mother left after receiving only a dose of Motrin. Neither appeared terribly pleased. I have trouble figuring out where the problem lies for the lapses in this patient’s care … The patient and her mother who doctor hop and get the same workups over and over again? Doctors who order the testing over and over again? Or maybe a system which creates no accountability? Perhaps a combination of all three. But how do we fix it?

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Healthcare Update — 04-15-2013

You can also see additional Healthcare Update stories at EP Monthly’s site. Interesting twist on medical negligence cases. A Nevada jury awarded three plaintiffs $24 million after being infected with Hepatitis C – allegedly after improper endoscopy sterilization procedures by gastroenterologist Dipak Desai. Vials of propofol and syringes used to inject the medication into IV lines were allegedly reused on multiple patients. Pharmaceutical company TEVA had previously settled claims related to the case. The interesting part of the case was that the jury also held that United HealthCare was liable because the physician was in United HealthCare’s network and because the United HealthCare didn’t properly inspect the quality of the medical care in the clinic – as is required under state law. Oh, and if that isn’t enough … the jury also awarded the plaintiffs a HALF BILLION dollars in punitive damages. This case is only at the trial court level right now, and United HealthCare has vowed to appeal the verdict. What type of unintended consequences will the verdict bring if it is allowed to stand? Know those background checks and how we’re going to keep guns out of the hands of patients with mental problems? One attorney has two clients whose New York State pistol permits were revoked after the police learned that the clients were using anti-anxiety medications. Wonder how many depressed and/or anxious New York State police officers will lose their jobs or be assigned to desk work because of this. Americans with Disabilities Act violation seems to come to mind. April Fools is over, right? Chinese man reportedly inserts eel in his rectum after watching it being done in an x-rated video. The eel then couldn’t get out, so it chewed its way through the patient’s bowel wall and was squirming around in the guy’s stomach. Xray of the abdomen is to the right. The patient went to emergency surgery to have the eel removed. The patient lived, but the eel died. Now the patient may face animal cruelty charges. I think the video he was watching was a prequel to “Alien.” We needed to perform a study for this? If pneumonia isn’t suspected, amoxicillin doesn’t cure lower respiratory tract infections (i.e. chest colds). If you do take amoxicillin for coughs, you’re much more likely to get nausea, rash, and/or diarrhea. One study patient even developed anaphylaxis from taking the amoxicillin. I’m relatively certain that we could apply the same study findings to Zithromax and Levaquin as well. Ahhh, but WhiteCoat, you say “I may not have pneumonia now, but this cough always turns into pneumonia and I need antibiotics to PREVENT me from getting pneumonia.” It just so happens that a study was just published about this topic as well. In a UK review of more than 1.5 million patient visits over 20 years, the researchers found that 12,255 patients would have to be treated with a course of antibiotics in order to prevent one hospitalization for pneumonia. And patients got antibiotics in two thirds of the primary care office visits, anyway. Wouldn’t be surprised if the cases progressing to pneumonia were due to resistant organisms from all the damn antibiotic prescriptions. And yes, doctors do prescribe too many antibiotics. This recent study shows that doctors prescribed 258 million courses of antibiotics – enough to treat more than 4 of 5 men, women, and children in this country each year. Antibiotic resistance is rising in several bacteria – the CDC is tracking at least 20 strains. Aunt brings child to hospital emergency department for “asthma attack”, staff examines patient and determines no emergency exists, ...

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