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Redefining the Pain Scale

The smiley faces just don’t seem to cut it any more. The Wong Baker pain scale was originally created for children. Now it is used by medical providers to precisely gauge pain in adults all over the United States because of the concept pushed on medical providers that “Pain is the Fifth Vital Sign.” Although this phrase was originally created by the Department of Veterans Affairs, The Joint Commission adopted it and ran with it, rolling out Pain Management Standards declaring in 2000 that “the pain management paradigm is about to shift,” that pain control was a “patient rights issue” and that providers would be required to measure pain on a 1-10 scale. See JAMA article here. PDF here. Skeptical Scalpel weighed in on the “Pain as a Fifth Vital Sign” issue in 2013. Of course now that the US is in the throes of an opiate epidemic because of the Joint Commission’s actions, the Joint Commission walked back its demands, stating that it only required providers to measure pain, not to use drugs and that it didn’t require the patient’s pain scale to reach “zero.” Then it put out a propaganda bulletin (.pdf) describing “Myths About The Joint Commission pain standards” … but that’s fodder for another post. So when I get to the whole pain rating thing and someone says his or her pain is a “10” while simultaneously munching on Cheetos and playing Flappy Bird on his or her TracFone, I have cause for concern. Either the patient is dissociated from reality, has some ulterior motive for overestimating his or her pain, or the patient doesn’t understand the pain scale. No matter how many times you shove the smiley faces in front of the patient’s smiley face, the patient just doesn’t get it. So sometimes I call them out. “Consider ’10’ as pain that is so bad that you are rolling around on the floor in agony and asking for someone to put you out of your misery.” [flap flap flap] “Oh, yeah,” [crunch chew chew chew] “it’s definitely a TEN” “Oh, but my unfortunate patient in distress, you’re not rolling around on the floor.” [Looking up from the screen momentarily] “OK, then it’s a 9 and a half” Brilliant. If only everyone could be so mathematically adept. There have been many memorable attempts to describe the pain scale. Brian Regan described his experiences trying to outmoan the patient in the next room, then discusses how he decided to describe his pain scale to the nurse. If you’re at work, don’t drink coffee while watching. If you’re at home, pop a beer and fire up the link. It’s worth 8 minutes of your time. Then there’s xkcd’s take on the pain scale – which piggybacks off of Brian Regan’s stand up routine. How would you rate your pain if 10 is the worst pain you could imagine … ? Allie from Hyperbole and a Half did an admirable job of it when she took her boyfriend to the hospital for vomiting Crasins and needing to be checked for Ebola. You really need to read that post for some good chuckles. So then I happened to come across an Improved Pain Scale picture on Reddit that does a reasonably good job at describing pain. View post on imgur.com Personally, I still like the Hyperbole and a Half scale better, but this Reddit one isn’t bad. And before someone out there tries to call me out for all of the links being in the Reddit post, the only one that I hadn’t seen before was the xkcd scale. I’ve passed around the links ...

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Antibiotic Apocalypse

The beginning of the antibiotic apocalypse may be nigh. Woman dies from the ultimate superbug – carbapenem-resistant Enterobacteriaceae (CRE) with New Delhi metallo-beta-lactamase (NDM). The bacterium is resistant to 26 different antibiotics. There were no antibiotics left to treat the infection – it was resistant to everything. Word on the street was that she was taking a Z-Pack for her cold before she got sick. Kidding about the Z-Pak thing, but this is no laughing matter. I thought it before and I still think it now – antibiotics should be treated like Norco and other controlled substances. Tracked. Patients who take too many of them should require special paperwork before they can fill prescriptions. All these unnecessary prescriptions for coughs and colds are just making the bugs stronger. We’re doing this to ourselves. Then again, scientists just announced that they have discovered a molecule that reverses antibiotic resistance in multiple strains of bacteria at once. The bad news is that some jerkoff investor will probably purchase the patent, jack the price for the molecule to about $17,000 per dose and will make sure that the molecule won’t be covered under Obamacare or any other insurance plans. The molecule is called a peptide-conjugated phosphorodiamidate morpholino oligomer or PPMO and works to disable the NDM-1 found in the most resistant bacteria. Powerful weapon to beat resistant organisms, but if we don’t change our prescribing habits and demands for antibiotics, it’s only a matter of time before the bugs learn how to beat the PPMO in this high-stakes game of cat and mouse. Is a post-antibiotic world approaching? This NY Times article again notes how the number of effective antibiotics in our arsenals is diminishing and that there isn’t much of an incentive for pharmaceutical companies to produce new antibiotics. The article states that Medicare has moved to require hospitals and nursing homes to adopt plans to prevent the spread of drug-resistant infections and to assure the proper use of antibiotics However, note that under the “Hospital Compare” program – created by the same government that wants to “assure the proper use of antibiotics” – hospitals are deemed substandard if they don’t throw strong antibiotics at every pneumonia within six hours of a patient’s presentation to the emergency department. Have those policies decreased pneumonia deaths since they were initiated? According to CDC data (.pdf file), deaths from influenza and pneumonia decreased from 18.4 per 100,000 population in 2006 to 15.1 per 100,000 population in 2014 – an 18% decrease (see page 37). During that same timeframe, the rate of death from all causes decreased from 791 per 100,000 to 724 per 100,000 – a 9% decrease (see page 35). I picked the cutoff date of 2006 because the Hospital Compare website started comparing hospitals in 2005. There are multiple confounding variables such as inability to separate influenza (viral-related and unaffected by antibiotics) from bacterial pneumonia that would be affected by antibiotics, the fact that pneumonia is a subjective diagnosis in many cases (was it pneumonia, CHF, or chronic interstitial changes?), that many deaths have more than one cause, and that financial incentives may make it more likely that pneumonias are underreported (readmissions for same diseases may not be paid by Medicare). Draw your own conclusions. A somewhat dated article, but one that shows the potential seriousness of a world in which we don’t have readily available effective antibiotics. In Venezuela, the imploding/imploded economy has made antibiotics largely unavailable and turned simple injuries such as a scraped knee into major health threats. One more infection-related article for the day. If you want to be ahead of the curve at medical dinner parties, learn ...

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Is Bad Medical Care Better Than No Medical Care?

In my past few shifts in the emergency department, I have seen the following patients who were seeking further care after being treated by other providers. One was a child who had been seen twice at an urgent care clinic. He had a fever of 103 degrees and wasn’t eating. The first time he went to the urgent care center, he was diagnosed with an ear infection. He was started on amoxicillin and sent home. He returned to the clinic 8 hours later because he still had the fever and still wasn’t eating. When the clinic provider looked in his mouth, he saw a red rash that appeared to be an allergic reaction. He was therefore changed from amoxicillin to Biaxin and started on Benadryl. The parents were concerned that his allergic reaction may get worse, so they left the urgent care clinic and came directly to the emergency department. When he came to the emergency department, he still had a fever, his ears looked fine, and he had the typical enanthem of herpangina. We stopped the antibiotics, stopped the Benadryl, gave the child some stronger pain medication, and had the parents feed him popsicles and cool liquids. Another patient had been in a bar fight several days prior. He had a cut on his knuckle and his knuckle was starting to hurt. He went to another emergency department and saw a provider who washed out the cut, started the patient on amoxicillin, and then put packing in the wound. When he came to our emergency department, we started IV antibiotics, removed the packing … from the joint … and sent the patient for surgery to clean out the infected joint and to repair the lacerated tendon. A third patient had been to both an urgent care clinic and an emergency department for evaluation of palpitations. The urgent care clinic diagnosed the patient with anxiety and discharged the patient with a prescription for Xanax. When the Xanax didn’t help and the palpitations were causing worsening shortness of breath, the patient went to an emergency department. There the patient was seen by a provider who performed an EKG and did a drug screen. The patient was told not to drink caffeine and given a refill for Xanax. When she came to our emergency department, an EKG showed Wolff Parkinson White syndrome. We got a copy of the EKG from the prior hospital and it showed the same thing. Their EKG even said “Ventricular pre-excitation, WPW pattern” on it. Finally was the patient in his 70s who was seen at another emergency department for evaluation of abdominal pain and no bowel movement for a couple of days. He had some lab tests done and the provider performed a rectal exam which showed that he had a lot of soft stool in his colon. So the patient received an enema and was discharged home with a diagnosis of constipation. He was told to take laxatives and eat more fiber. When he came to our emergency department by ambulance later that evening because he vomited the Milk of Magnesia, his abdomen was swollen and tympanitic. He had low blood pressure, no bowel sounds, and a sigmoid volvulus with an obstruction on x-ray. He also went straight to surgery. I understand that it is considered bad form to question the care of other practitioners. If another provider’s care is criticized, often the criticisms are met with allegations of elitism and hindsight bias followed by a plethora of anecdotes about how those commenting were able to catch some other provider’s mistakes. You don’t know which patients, ...

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Bloated Healthcare Costs: Are Emergency Physicians to Blame?

By Birdstrike M.D.   In an article entitled, ”Why the ER Admits Too Many Patients,” Dr. Michael Kirsch tries to explain that Emergency Department admissions are inflated due to Emergency Physicians acting in their own self-interest.  Many Emergency Physicians have read this and taken offense, feeling that his assertions point unfair blame on them for a significant portion of excesses in medical care and costs.  I share this visceral reaction in part, but such a reaction blurs some very important points worth examining.  Let’s give the benefit of the doubt for a moment, that the author may in fact be pointing the blame not at Emergency Physicians personally, but at a broken “system” instead. First, he claims that due to fears of potential lawsuits, Emergency Physicians when in doubt, cautiously err on the side of admitting a patient and ordering tests, rather than discharging them with minimal work up.  How any Emergency Physician can deny that this happens baffles me, as almost every one I’ve ever known will say in private they think about, and are motivated to avoid the threat of lawsuits (except for possibly a few in the handful of states with strong tort reform).  Physician surveys seem to support this, with at least one showing >90% of physicians across multiple specialties admitting to such.  This speaks to the greater issue of defensive medicine and the need for tort reform, and should not be seen as an indictment of Emergency Physicians.  Tort reform is an issue where the American people just plain need to decide.  Do they want to keep their cake uncut, or to eat it?  You absolutely cannot cling to the pipe dream of reducing unnecessary medical testing and expensive overly-cautious admissions while holding true to the good old-fashioned American past time of suing the pants off of a doctor who sends a patient home, only to have something unexpected go wrong.  Decide: Do you want, A-Doctors to send you home, cancel your test, and throw caution to the wind when you might be sick to save costs for the “greater system,” and give up the right to sue if something goes wrong, or, B-Do you want to retain the right to sue in court for hundreds of thousands of dollars (or even millions) if you have a bad outcome and have doctors admit you when in doubt and order every test (expensive or not) that they think they need to keep that from happening? You cannot have both A and B.   For the most part, and in most states in the land, the American people, their elected politicians and the plaintiff’s attorneys that support them, have already decided in favor of option B.  The right to sue has always come out on top (in most states) and there’s no sign that’s about to change any time soon.  To those who will respond with “science,” “data” and articles claiming the threat of medical malpractice doesn’t alter doctors’ practices or inflate healthcare costs, don’t bother.  Most physicians are not interested in hearing evidence or “data” to show oxygen isn’t needed for breathing, or that 2+2 isn’t 4, either.  There are some things we as doctors know to be self-evident.  To the extent that one blames such a drive to err on the side of admitting patients on a dysfunctional medical malpractice system, is the extent to which he is correct.  To the extent one points the finger specifically at Emergency Physicians, who have no choice in this day and age but to admit patients with the utmost of caution when in doubt, is the extent to which ...

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Press Ganey’s Latest Business Model: Eavesdropping

A reader provided me with a report showing that in addition to the “let’s get hospital administrators to rely on invalid patient satisfaction statistics” business, Press Ganey is also in the “let’s eavesdrop on what are supposed to be private physician patient conversations” business. People acting on Press Ganey’s behalf are supposedly showing up in hospitals to evaluate the hospital settings … and snoop through patient’s protected health information in the hospital … and even eavesdrop on what are supposed to be private conversations between patients and their physicians in restricted areas. Below are some excerpts from the report I received which are transcribed for web searching purposes. Press Ganey apparently printed its report on dark paper in an attempt to make the report difficult to copy. Transcription: Sitting against the wall by the printer there is a sheet of patient labels with PHI that anyone can see when walking down the hallway. ED was very busy with all days [sic] occupied. The ED received three ambulance patients almost simultaneously while I was there. A new patient arrived via EMS. Initially, when the doctor and nurse went into the room, no one pulled the curtain for privacy. After the doctor exited the room, the nurse then pulled the curtain. During this interaction, the doctor explained what he was doing throughout the process and asked the patient’s permission, saying for example “can I listen to your heart and lungs?” A patient who was brought in via ambulance for alcohol abuse was very belligerent with the nurse. The patient told the nurse “don’t put one of those gowns on me.” The nurse said he wouldn’t put one on now, but would need to later. Then the nurse tried to put the patient in a gown again. The patient stated it was too cold to get undressed. The nurse offered warm blanket. Patient cursed and said to call administration down to the emergency department. The patient told the nurse to f*** you.” The nurse addressed the patient’s comments but in doing so also said the word “f***.” The nurse was doing a decent job of handling a very difficult patient but I did not think was appropriate occurs even if in addressing the patient comments. The patients who had arrived in the waiting room during my observations starting at 1703 were all still sitting in the waiting room I exited the emergency department. This included a teenage boy who was triaged at 1714, an infant boy, and another woman. Were these patients ever rounded on? I observed the patient being called back to a treatment room. The patient was called be a very loud overhead paid for number 4621 to come to the front desk. “Number 4621 to the front desk please.” You could hear the phone tone after the message until the receiver was hung up. The patient assigned number 4621 went to the front desk. The patient family waited to be addressed, and while they were standing at the desk, they paged the patient again. This process was very impersonal. How are patients who have disabilities assisted? The person creating this report appears to have little knowledge about hospital procedures, about emergency department flow, or about legal issues. Your correct response to a patient who is repeatedly verbally abusive to you and for whom you have no choice but to stabilize and treat should be … And when an emergency department is full and gets three ambulance runs in a row, the first thing on the overworked staff’s mind should be to go out in the emergency department waiting room and ...

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Physician Bodyguards and Government Policies

Chinese hospitals recruiting 1500 “guardian angels” to protect doctors from violent patient attacks. Patients who are angry about the Chinese healthcare system, medical expenses, long waiting times, and uncaring doctors have become more violent over the years, with violent attacks occurring every two weeks on average – according to state media – which in reality means that it probably occurs a lot more frequently than twice a month. Now China is starting a campaign to get volunteer students, medical staff and other patients to intervene when patients are upset with physicians. Apparently China views non-physicians as being more expendable when patients become upset and brandish cutlery. At least we have concealed carry laws in the US … for now. Interesting that according to the article, China has created a culture in which “doctors are in crisis” and in which “medical practice in China is a high-risk job.” Now China is vowing to “root out corruption in the healthcare system” – to save all the patients from the evil and corrupt medical providers. In reality, China’s policies have created many of the problems it seeks to “root out”, but state-run media likely won’t put that in print, either. After reading through the article, think about what it happening in the US right now. Doctor rating sites and patient satisfaction take precedence over proper medical care. Patients are forced to purchase government-mandated “insurance” that in many cases doesn’t pay for the cost of care and that many doctors will therefore not accept as payment. Losing money every time that you provide medical care to patients – while paying off student loans, paying office overhead and salaries, paying malpractice insurance premiums, and paying licensure fees – is just not a sustainable business plan. As a result, patients pay a lot of money for government insurance but they often have difficulty finding medical care when they need it. Federal agencies, in order to improve “transparency,” publish a list of how much money the federal government is paying physicians so that it can make physicians look like overpaid whiners when they complain about their workload and the regulatory burdens of a medical practice … but the same federal agencies refuse to publish statistics about patients who abuse the system (“privacy rights” apparently outweigh the public’s right to know about illegal acts) and the same government hides data about maltreatment of patients in its own facilities. “Transparency” indeed. Regulations related to the provision of medical care rise exponentially and educational costs to become a physician steadily increase while payments for medical services steadily decline. The pervasive media message is what a lousy job physicians are doing. Increased malpractice. Unnecessary testing. Missed diagnoses. Malpractice verdict after malpractice verdict. Hundreds of thousands of deaths each year from hospital errors. A well-respected profession is now becoming despised. By systematically making the practice of medicine more difficult and less appealing, the United States is slowly creating a crisis similar to that which China is experiencing now. The more insidious problem is that it takes at least 10 years and sometimes up to 14 years to educate and train a new physician. Cause the best and brightest students to shy away from medicine while older physicians retire or die off and in 5-10 years there will be an even larger crisis that will be impossible to immediately solve. At that point, it may no longer be an issue of which doctor you will choose to treat your medical problems, but instead a question of which doctor will choose to accept you as a patient. Then who will the government and President Obama ...

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