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Healthcare Updates

Links and commentary to healthcare news around the internet

Healthcare Update — 08-01-2012

Bank robber gets shot in hand while trying to run over state troopers. Brought to emergency department and prescribed pain medication. When he returned to jail, the nurse gave him Tylenol #3 instead. Inmate then sued everyone for $2 million. Fortunately, a judge dismissed the case. Something wrong with this picture? Woman has “mommy makeover” surgery but is left on birth control pills, later suffers a blood clot to the lungs and dies. Man then listens to his 911 call for the first time … with his attorney rubbing his shoulder … while being videotaped … and while two other people take pictures … including large boards saying “DEADLY COMBINATION” and “Drs Knew” in the background … which are then published in a FLORIDA newspaper. At least there’s no way that a judge would let such evidence be presented at trial. Fast and Furious part deux. DEA steals truck from private trucking company, uses truck to transport marijuana in a sting operation, truck and driver get shot up, then DEA returns bullet-ridden truck to its owners and shrugs its shoulders. Damages to business owner top $100,000 and DEA won’t pay up. I wanna try me that with one of them there federal mail trucks and see how far I get.

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Why Some People Just Will Never Get It

By BirdStrike M.D. This post was inspired by a brilliant response by Lior to WhiteCoat’s excellent article “Jim Dwyer New York Times Pediatric Fever Article Debate” on this very blog.  First, what should not be lost in this back and forth debate are Rory Staunton and his family.  I give my deepest condolences to the family of Rory Staunton. As a parent, I cannot imagine their pain. I wish them and the rest of his family the best. I sincerely wish that this had not happened, and that this outcome never happens to a child again.  My intent is not to “take sides” or play judge and jury over the treatment in this case.  In contrast, I would like to underscore what it is like to be an Emergency Physician, and how sometimes tragic and devastating outcomes can occur, when a competent, concerned, hardworking Emergency Physician does everything right.  I think Lior gets it like very few non-medical people ever will. Put another way: 1. Common things presenting commonly- When a patient presents with something common with its usual symptoms, the diagnosis is obvious to medical practitioners and even lay people.  Runny nose, dry cough = common cold.  99% of the time that equation is correct.  We all get it. 2. Uncommon things presenting commonly- The difficulty of a diagnosis increases significantly when a patient presents with an uncommon condition, yet with its typical symptoms. Physicians typically are well trained to make such diagnoses.  Petechial rash, fever, stiff neck = devastating, fortunately uncommon, but easy to identify: Meningococcal meningitis.  Cases like this are easy, even if you’ve never seen them.  This is what doctors do. 3. Rare things presenting commonly- Once again, the difficulty of diagnosis jumps even more dramatically when a patient presents with a very rare and unlikely condition, yet with its typical symptoms. Again, physicians typically do a good job here; this is what board exams prepare for, finding the “needle in the haystack”.  A 14 year old male with tearing back pain between his shoulder blades = Marfan’s Syndrome with thoracic aortic dissection and impending death.  Rare, thank God, and easy to miss if you are not extremely careful, but right out of the textbook if you are so unfortunate to see this case and fortunate enough to recognize it. 4. Uncommon things presenting uncommonly- When a patient presents with an uncommon, or worse yet rare condition, presenting with symptoms that are unusual even for the uncommon condition itself, the difficulty of making the diagnosis increases logarithmically to the point where missing the diagnosis is essentially expected.  Others have put it like this:  there are some diseases that are so uncommon, and can present so unusually that it is essentially the standard of care to miss them.  The 11 year old boy with nausea, sweating with pain down his arm:  It’s obvious, right?  It’s obvious what this is.  It’s an early case of sepsis, from a cut on the arm, presently very strangely, correct?  After all, the heart rate is 130.  The respiratory rate is high.  The temp is 100.1 F.  “He’s just not right.”  It’s sepsis, right……?  Maybe it is a viral gastroenteritis.  Or what if I told you the boy was a chronic complainer, and faked sick to get out of school many times?  And after some nausea medicine, he says he feels a little bit better and just wants to go home… But his chest hurts, too.  And when he was younger he had Kawasaki syndrome, which was treated, but caught very late.  Would you know that he was dying in front of you ...

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Healthcare Update — 07-25-2012

Stop calling it a tax, dammit! Under the Affordable Care Act, business owners will pay $4 billion more in taxes. Now the Congressional Budget Office is calling it a “penalty tax.” NY Times journalist Jim Dwyer dislocates shoulder patting himself on back for getting NYU hospital to change policies after writing poorly-researched article on sepsis triage. Goes to emergency department shaking in pain with pulse of 95 and respiratory rate of 22. Is immediately put into sepsis pathway. Phew. Close call. Now that’s what I call security. Armed police officers stand with automatic weapons outside entrance of emergency department in Honduras after gang fights break out in the local jail. Kind of an imposing picture. Patients gone wild. Nebraska man walks into emergency department with gun and knife threatening “bodily harm” to one of the emergency physician. When he found out the physician wasn’t working that day, he demanded to know where the doctor lived. Police called and patient then became suicidal. Taken into protective custody. Where are those armed guards when you need them? What do you get when you cross a monster truck with a “bamblance”? No, not a crushed ambulance. Introducing … the WHAMBULANCE. And if you guessed that this was created somewhere in the back bayou, you’re wrong. It’s being showcased not too far from Houston, TX. If anyone in the Lone Star State wants to go get some video footage or pictures, I’d be happy to post it. The worst drought in recent history isn’t just hurting crops. Missouri declares state of emergency after summer heat kills 25, causes 829 ED visits, and increases risk of fire. Heat-related emergency department visits also double in Oakland County, MI [thanks to Zoltania for catching the typo and letting everyone know that the weather is fine in CA this summer]. As patient volumes nearly double, hospitals in both Australia and New Zealand tell people to stop coming to the emergency department for colds and influenza. One of the commenters to the New Zealand article notes that “as long as doctors continue to charge outrageous prices [the ED is] exactly where i will keep going after hours.” Ophthalmology residents on call. New technology being studied at Emory University suggests that taking photographs of a patient’s retina and sending them to an ophthalmologist for review may help triaging patients with headaches, severe high blood pressure, neurologic changes, or vision problems. Worcestershire consultant states that closing emergency department may improve patient care and solve staffing shortages “in one go.” If patients were worried that things like stroke and heart attacks wouldn’t get timely treatment because they’d have to travel further by ambulance to get medical care, they shouldn’t be. The consultant knows from experience that “it’s very, very rare that the increased journey time makes any difference to a patient’s outcome.” Maybe the UK could just have one giant emergency department to treat everyone. Imagine how much better the care would be then. Muskogee Community Hospital in Oklahoma closing its emergency department effective July 31, 2012 and encouraging all patients to go to the other medical center in town. People commenting to the article don’t seem to think that care will be improved as a result of this move. “Serial infector” caught in New Hampshire. When patients were supposed to receive fentanyl, this schmuck would inject himself with the medication then replace the medication in the syringe with water. Bigger issue was that he had Hepatitis C and his dirty needles were unknowingly used on cath lab patients, causing 31 patients to contract Hepatitis C as well.

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Chief Violetté and the Headless Trauma

By Birdstrike M.D. It was intern year of my Emergency Medicine residency.  I was on my trauma surgery rotation and working at least 100 hours per week (pre-ACGME regulations). To say that I was burned out and sleep deprived would be an understatement.  It was three weeks into residency and I had done nothing but change dressings on my Chief resident’s patients’ putrid decubitus ulcers, run to get gauze packets, perform rectal exams, “RETRACT!”, and be the butt of senior resident jokes.  I had learned so few real skills in procedures or anything else that I was seriously ready to quit at this point, but in way too much student loan debt to do so.  I can’t tell you how many times I prayed for this guy to end up blind, impotent and in an adult diaper.  My supervising resident, Chief “Violate” … I’m sorry, let me rev up my French accent, Chief Violetté was infamous for getting his first two surgical residencies shutdown due to his generally abusive nature, not to mention his penchant for being an exquisite jerk at the perfect moment.  At his program’s ACGME site visit, when he was asked why he logged 168 work hours three weeks in a row during his first surgery rotation, his response was,“I wanted to work 170 hours, but when I got to 168, there were no more hours left in the week!”  I must say, despite being a bastard with no equal, old Chief “Violate”(as I will refer to him from now on), made me take my game to another level. It’s Saturday night.  I’m on call.  I’m dead asleep, and let’s just say I’m feeling a little “pukey” and abso-friggin’-lutely exhausted from having a little too much fun the night before at the local nursing school graduation after-party.  I hear this insanely loud pounding on my call room door and our medical student is screaming, “Wake up!  Wake up!  The Chief’s got an intubation for you!  He wants you in the trauma bay in 30 seconds!!” In a deep circadian haze, I run down to the trauma bay,  and Chief Violate grabs my ear, pulls me into trauma room 1 and says, “I’ve got a procedure for you, big boy.”  I look down at the patient on the stretcher and see a pair of boots, blue jeans, a belt, a man’s tattooed chest, a perfectly normal neck and … a bloody stump of a partial-head pouring out blood like a lawn sprinkler.  As my sphincter tone increases rapidly to diamond cutting levels, the Chief puts a Mac 3 in my left hand and a 7.5 ET tube in the other, pushes me to the head of the bed and says, “You’ve been whining about not getting any good procedures, so cock, lock and get ready to rock, tough guy!” To everyone’s shock and amazement, the guy is alive!  He’s conscious!  Choking on blood he screams, “Finish me off!  Finish me off, and put me out of my misery, you bastards!”  Apparently, instead of pointing the shotgun at the back of his throat towards his brainstem which would certainly have been instantly fatal, he put it in his mouth and pointed upwards, tearing off his upper teeth, maxilla, nose, eyes, forehead and frontal skull, leaving the key parts of his brain intact. As my heart rate creeps up to near SVT levels, the Chief painfully flicks my ear and says, “What the hell are you waiting for?  Intubate him, All-Star!  Don’t worry.  This will be the easiest airway of your life.”  Only having intubated sedated animals and rubber dummies ...

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Jim Dwyer New York Times Pediatric Fever Article Debate

This is probably a record length post for me, but I thought it was important to respond to Mr. Dwyer’s comments to a post written on this blog regarding the article he wrote that appears in the NY Times. I had planned to leave my comments after his, but they became too long and involved and I also wanted to paste a couple of pictures from Mr. Dwyer’s article, so I instead decided to answer his criticisms in a post. If any of you were wondering, I was not the anonymous physician who authored the previous post on Mr. Dwyer’s article. I spent most of my afternoon creating this response because Mr. Dwyer’s original article was somewhat frustrating to me, but I found his justifications and explanations for what was contained in his article to be misleading. UPDATE See additional commentary about Mr. Dwyer’s articles here and here. ———————————————————- Dear Mr. Dwyer, When re-reading your article, I absolutely agree with Rory’s wish that no other child – and no other family for that matter – should have to go through what Rory went through. He sounded like a great kid and he obviously had a close family and a bright future. As you also mentioned, Rory’s uncle was a friend of yours, so I can imagine that this incident affected you more than most other investigations you have performed. This topic hit home for me as well. My daughter nearly died from an invasive pneumococcal infection when she was younger. She was hospitalized for a week in a university medical center on triple antibiotics. Very scary times and we thank God that things turned out well. So let’s go through your article and responses you made to the criticism about your article so that we can determine how to prevent kids from dying from sepsis due to invasive organisms. JIM DWYER COMMENT: 1. You say that the stop sepsis campaign is for tracking severe sepsis. That misstates both the nature of the campaign and my citation of it in the article. The campaign’s goal is to aggressively identify sepsis and begin treatment within an hour. (The tracking of cases you cite is secondary.) To begin the process of identification, the initiative created a triage screening tool which gives a list of 8 signs and calls for additional investigation if a patient has three of them. As I wrote, Rory Staunton had two when he came into the ER. He had three when he was leaving. (BTW — his heart rate over a period of two hours ranged from 131 to 143. That’s in the article, too.) In the distribution literature with the screening tool, there is no distinction between pediatric and adult patients. Whether or not you think the values are relevant to a 12 year old, 5’9″, 169 lb boy, Rory was assessed for possible sepsis in triage. Let’s look at the sepsis criteria according to the checklist that you posted. Then let’s apply them to children. 1. Pulse greater than 90. In children up to 2 years of age, a pulse rate less than 90 is considered too slow. In other words, ALL children up to 2 years of age should have a pulse rate greater than 90. 2. Respiratory rate greater than 20. In children up to 5 years of age, a respiratory rate less than 20 is considered too slow. In other words, ALL children up to 5 years of age should have a respiratory rate greater than 20. So now in children who have entirely normal vital signs for their age, right away you have ...

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Jim Dwyer New York Times Article – Irresponsible Journalism?

By an Anonymous Emergency Physician The opinion piece below was written by an emergency physician regarding a New York Times article by Jim Dwyer (picture at right). The author did not want to be identified due to fears of retribution from either the NY Times or from the hospital at which the physician is employed. In addition to the points the author raises below, I would add these additional points of information: 1. The “Stop Sepsis” campaign cited in Mr. Dwyer’s article specifically stated that it is only to be used for tracking patients with severe sepsis and that “only those patients who are hypotensive after being given 2L of fluids or that have an elevated lactate should be entered in the data portal for this Collaborative.” Rory was not hypotensive and no lactate level was included in the labs pictured in Mr. Dwyer’s article. Mr. Dwyer never mentions any of these facts. The Collaborative does not allow access to links on this page describing its screening tools or to how it believes that a determination for ordering a lactate level should be made. I will also note that Mr. Dwyer responded to some of the more than 1600 comments to his article, including some of the issues raised below, in this follow up article. -WC UPDATE JULY 22, 2012 Also see an important update to this debate at this link. —————————————— The New York Times published an incredibly sad story about a 12 year old boy named Rory who went into the NYU emergency department, was diagnosed with gastroenteritis (a viral stomach bug), and who was dead two days later from septic shock.  Those are just about the only facts that are not in dispute.  The rest of the New York Times article seems to build a mountain of evidence as to why the emergency physician screwed up.  However, as is frequently the case, the truth is much more complicated than the media would have you believe.  There are lots of comments from other doctors using the almighty retrospectoscope and so many clinical inaccuracies discussed that this sad story is turned into a piece of sensationalistic journalism. This post is mostly for the non-medical people that read this blog to help you understand the medical issues a little better.  This is a scientific discussion of the main inaccuracies of the article followed by what possibly could have been done better.  I say “possibly” because I did not examine the patient and all of my information is through the New York Times article.  If you have already read the article and decided that the ED doctor screwed up and nothing can change your mind, then stop reading.  If you want a fair and evidence-based discussion of the article then read on. The article references the “Stop Sepsis” campaign and says that the vital signs that should have triggered an evaluation for severe sepsis.  The article says that Rory had initial vital signs of a temperature of 102, a heart rate of 140, and then points to the Stop Sepsis guidelines.  There are two problems with this: First, the Stop Sepsis guidelines are intended to be used in adults, not in children. Second, just because a patient has abnormal vital signs doesn’t mean that they have severe sepsis.  Most patients in a pediatric ED waiting room would meet these criteria and yet they don’t have severe sepsis.  The “Stop Sepsis” guidelines are a screening tool that can suggest sepsis but they have to be used in the right clinical context.  Most physicians see pediatric patients every day who meet the “Stop ...

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