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Healthcare Updates

Links and commentary to healthcare news around the internet

Slow ventricular tachycardia

Among the many patients waiting for a telemetry bed was a rather large gentleman with a history of heart disease and arrhythmias. He was sitting in his bed eating dinner when the resident went to re-evaluate him. As the resident approached the patient’s bed he became concerned with the tracing on the monitor. In a nervous voice he yelled across the ED “Dr. Whitecoat! Come quick! The patient in Bed 8 is in slow ventricular tachycardia!” One of my favorite nurses raised her eyebrows and saw that the patient was busily finishing his peach cobbler – oblivious to the frantic calls for help. She slowly sauntered toward the patient’s bed. As I poked my head out from behind Curtain Number Three, my hands full of blood from the squirting dialysis graft, I saw the nurse do a U-turn in the hall, shake her head, and mutter over her shoulder “that’s the pulse oximeter you dumbass.” The resident looked at me, shrugged his shoulders, and said “I’m so embarrassed.” I really do love my job (and the people I work with).

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Waking "Unresponsive" Patients

Ever have a patient who is brought in “unresponsive”? You know — the ones who blink their eyes when you touch their face and the ones whose hands always seem to drift to the side when held over their face and dropped. How to wake them??? Here’s a list of techniques that have been suggested by various authorities on the matter. Painful stimuli are the most commonly used techniques. Sternal rubs, pressure to the nailbeds, and pressure to the supraorbital nerves have all been employed. One authority related the story about a patient who would not get off a stretcher when brought to the ED by an ambulance because the last time he came there unconscious the “motherf***ing doctor punched me in the chest and left a bruise.” Translate that into “the physician performed a vigorous sternal rub that brought the patient out of his unconscious state.” Ammonia inhalants sometimes work – until the patients hold their breath. Do not stick one inhalant in each nostril and squeeze. Doing so could cause chemical burns. Dripping water on the forehead or eyes also seems to work fairly well. This one has few side effects, but either dress in protective gear or have a towel ready in case the patient suddenly wakes up spitting. One authority suggested inserting a cotton swab down the patient’s nostril. The authority stopped performing this maneuver when one patient suddenly turned her head to the side and the cotton swab snapped off in her nose. Fear Factor: Saying in a loud voice “OK, lets cut the clothes off and put the catheter in the bladder” also seems to work. One expert on the matter related a story about a gentleman who was chronically intoxicated and repeatedly came to the emergency department “unconscious.” The paramedics repeatedly cut off his clothing, including his winter coat, in order to assess for occult injuries. After the patient sobered up, the ED staff would call his parents and tell them that he needed a set of clothing and a ride home. At one point the patient’s exasperated father politely asked “would you please stop cutting off his clothes . . . we have bought seven new coats in the past two months.” Any new techniques we are missing?

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Mr. Wayne

We had a well-known patient return for evaluation yesterday. He has some challenging complaints on previous visits. Looking through his history, below are some of the more memorable complaints. Yes, his name has been changed. Touched compressor with petroleum on it. Touched same hand to mouth and got diarrhea. Wanted to know if he was poisoned. Walking past janitor with open bottle of water, janitor jerked bucket and blue disinfectant splashed onto open water bottle. Thinks that disinfectant may have gotten into his water. Took one sip, didn’t taste anything. Took another sip thought it may have tasted like disinfectant. Called poison control which allegedly couldn’t tell him if he was poisoned or not. Wanted to be tested for disinfectant poisoning. Aciphex taken 4 hours and 10 minutes too soon. Wants to know if he could have any bad effects from it. Drank water out of styrofoam cup and had burning to the back of his throat. Drank water from several other styrofoam cups and still had burning to throat. Brought cups into be tested for poison. Sent home from ER. Seen in physician’s office following day and given nystatin rinses. Purchased ham sandwich out of vending machine in basement of hospital. Had packet of mayonnaise wrapped inside, and put on sandwich, but thinks mayonnaise was warm and may have poisoned him. Walked by nurse in hall who was shaking an IV bag to mix contents. Thinks that some of contents may have sprayed onto him and contaminated him. Came to ER twice within 24 hours for nausea. Given GI cocktails on both occasions. Came back third time to ask if that was too much medicine to take in 24 hours. Ate “soggy” hamburger at local restaurant because he was hungry. Came in late at night because he didn’t think he should have eaten hamburger when it was soggy. Given glass of water in ER after given GI cocktail. Said it tasted like alcohol and wanted to know if we were poisoning him. Opened piece of gum and began chewing it. Thought gum tasted like metal. Came in to see if he swallowed tin foil. Ate can of Campbell’s soup that tasted too “tangy.” Came in two weeks later for eating another can of Campbell’s soup that tasted too tangy. Came to be tested for dehydration. Physician told him that only way to do so was to insert Foley catheter to measure urine output. Left without further treatment. Licked scissors with something on them. Washed lips with Coast soap and then thought he poisoned himself with the soap. Called poison control and was told that people could definitely poison themselves with Coast soap — he should only use Dove soap. Twitching more than usual. Took Maalox and Prilosec at same time. Feels sick. Cleaning refrigerator and got cleaner fluid on hands. Thinks he was poisoned. Constipated, drank cup coffee, now has diarrhea. Ate piece of turkey, accidentally ate “red stuff” near bone along with it. Feels nauseous. Thinks turkey wasn’t cooked all the way. Called Poison Control and told not to worry. Came to ER at 3AM on Christmas night to be checked anyway. Given bottle of amoxicillin for infection. Took tin foil seal off, but there was still some sticking out off of the edge of the bottle. Brought bottle in and thought he may have swallowed tin foil. Nurse asked him if he was drinking pills out of the bottle. He replied “no.” Nurse asked him how the metal would have gotten into his mouth. Stated he “might have poured some of it out” (no, this didn’t make ...

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Hospitals Getting Graded Using Wrong Test Questions

So the Department of Health and Human Services’ “report card” grading hospitals on how well the hospitals “care for all their adult patients with certain medical conditions” just keeps getting worse and worse. Now we’re seeing that the “quality indicators” the government is using are nothing of the sort. One recent study shows that at least one set of “quality indicators” Increases the likelihood of misdiagnosis, Causes patients to receive unnecessary antibiotics, Has no effect on patient length of stay or death rates Not mentioned in the article, but just as important – increases the costs that patients have to pay due to all the unnecessary antibiotics and blood cultures Jumping through all the government hoops makes patients more likely to be misdiagnosed and more likely to receive unnecessary antibiotics. And they’re the ones grading the hospitals? The HHS home page states “This information will help you compare the quality of care hospitals provide.” Funny thing . . . if you look around on the web site, it shows nothing about where the quality indicators came from or what scientific methods were used to come up with the indicators. This page lists all of the quality indicators that HHS uses to determine whether or not patients are receiving “quality care.” If you go to the Pneumonia “Process of Care Measures” you’ll see that HHS thinks that “quality hospitals” give antibiotics within 4 hours because “Timely use of antibiotics can improve the treatment of pneumonia caused by bacteria.” Great. So why the 4 hour time frame? There are no data on the web site to support the government’s “quality indicators.” Now at least one study shows that the 4 hour time frame may actually harm patients. And why does HHS equate quality of care with giving unnecessary antibiotics to patients with viral pneumonia? Some of the quality indicators are valid. But let’s not use smoke and mirrors to coerce hospitals into providing unnecessary and potentially harmful care so that they can be at the top of some report card. The patients in the US deserve better than this. On tap in the future – more than 100 new “quality indicators” by which hospitals will be expected to abide. Just how many of them will have a scientific basis? I’m not keeping my hopes up. This micromanagement is going to make healthcare in the US more expensive and less effective. One more thing – has anyone ever noticed that government-run hospitals aren’t on the HHS “Hospital Compare” website? Try searching for Walter Reed Army Medical Center or Tripler Army Medical Center, for example. If civilian hospitals are performing as well as government-run facilities, they should get a great grade, right? Why aren’t government-run hospitals available for comparison? Bottom line: If everyone ignores these indicators, they become meaningless. No quality indicators for the Department of Health and Human Services leadership . . . yet.

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Refuse Medicaid patients, get sued

According to a July 23 article in AM News, the Illinois attorney general is suing two Illinois clinics because they made a business decision not to accept new Medicaid patients. Let’s look at the facts: According to the AMA, Illinois is one of 17 states in a medical liability crisis. Three of the American Tort Reform Association’s top six “judicial hellholes” are located in Illinois. Illinois pays next to nothing for physicians to see Medicaid patients. This article implies that Illinois is paying physicians $30 per visit for Medicaid patients when it costs the physicians $300 per hour just to keep the doors open. No, I take that back. In some cases, Illinois doesn’t pay next to nothing to healthcare providers who see Medicaid patients. Instead, Illinois pays nothing at all. Illinois’ Medicaid program already owes $1.5 billion in late payments to pharmacists, doctors, nursing homes, and other medical providers who have provided care to Medicaid patients. See the article “Illinois Medicaid Takes on New Costs – Governor accused of ignoring unpaid bills” and the article “Illinois’ Medicaid money to hospitals MIA“. Oh, and by the way, the public hospitals in Cook County are cutting services because the county and state don’t have the money to pay for them. See Doctors leaving Stroger Hospital So Illinois has one of the worst malpractice climates in the US, it costs the involved clinics money every time they see a state-funded patient, the state isn’t paying the clinics the small amount of money the state owes them for taking care of state-funded patients, and the state is partly to blame for closures at the county hospitals where state-funded patients could go to be seen. The clinics make a responsible business decision to stop seeing patients because they lose money and increase liability every time they take care of a patient. Now Lisa Madigan has the gall to sue the clinics? Let’s look at what will happen if this lawsuit is successful: Illinois continues to collect billions of dollars in taxes to fund care of public aid patients Illinois cuts back on more medical services and closes more public clinics because of “lack of funding” Public aid patients have nowhere to go for care, so they seek care at private clinics State doesn’t pay private clinics for taking care of public aid patients Private clinics lose more and more money until they make business decision to stop seeing public aid patients State sues private clinics to force them to continue caring for publicly-funded patients without being paid or being grossly underpaid State saves billions of dollars per year in what amounts to court-ordered involuntary servitude against health care providers. Good business decision, Ms. Madigan. Way to attract more health care providers to do business in Illinois. What’s next – suing people who decide to quit their state government jobs to force them to keep working for substandard wages? Does your dad have anything to do with this lawsuit? I included the complete text of the AM News article below for those who don’t have access to the AM News web site.

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