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Tag Archives: Medical Studies

Medicaid Recipients Twice as Likely to be ED Patients

A study just published in the Annals of Emergency Medicine shows something that many people suspected: Patients with Medicaid (i.e. government “insurance”) tend to use the emergency department much more often than patients with private insurance. After studying 230,000 participants in the National Health Interview Survey, the researchers found that Medicaid patients were more than twice as likely to use the emergency department as their privately-insured counterparts. When barriers to timely primary care were added into the picture (including difficulty reaching doctor on telephone, difficulty obtaining timely appointment, long waits in the physician’s office, limited clinic hours, and lack of transportation), emergency department utilization increased significantly. 40% of Medicaid patients had used the emergency department more than once in the prior year. 51% of Medicaid patients with one barrier had more than one ED visit in the prior year and 61% of patients with two or more barriers had more than one ED visit in the prior year. I’m sure that there are other reasons for the higher than normal emergency department utilization, the biggest one being lack of a disincentive for using emergency departments versus primary care physicians. The article concluded that “Expansion of Medicaid eligibility alone may not be sufficient to improve health care access.” Insurance doesn’t equal access. Wonder where I’ve heard that before ….

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Literature Pearls

A few interesting topics caught my eye in the literature lately. From the Journal of Emergency Medicine (full article on Medscape): Tessalon Perles can be dangerous in an overdose. This case report shows how a teenager who took 10 pills in a suicide attempt presented in cardiac arrest, was successfully resusciatated, then ended up losing her eyesight and developing permanent psychiatric problems. From an eMedHome.com Clinical Pearl: Aggressive diuresis in patients with neurogenic pulmonary edema may worsen outcomes. Delayed cerebral ischemia is the most common cause of secondary neurologic injuries in patients with aneurysmal subarachnoid hemorrhage. By reducing preload through diuresis, the resulting hypovolemia may decrease cerebral perfusion pressures and cause additional neurologic injury. Recommendations are instead to maintain normovolemia and use positive pressure ventilation to maintain respiratory status. References here and here. Has any one tried this? The constipation may be nasty, but the treatment can kill you. Retrospective review shows that Fleets enemas in standard doses can cause renal failure, severe electrolyte abnormalities, and even death in elderly patients. Back to the ol’ “high, hot and helluva lot” soap suds enemas?

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The Angry Mime

An older gentleman comes in because he has a “sinus infection” for the past couple of days. As soon as the triage nurse brings him back, she’s already whispering to the other nurses. Later, I learned that she told them to make sure that I get the patient. She’ll get her paybacks later. The man was upset because the ZeePack he got from his primary care physician wasn’t working after he had taken a couple of doses. He wanted some stronger antibiotics “like Augmentin or some Levaquin 750s” to make sure that his sinus infections went away. Triage nurse is really going to get her paybacks. I examined him. He had no sinus infection. He had sinus congestion at best, but even that was questionable. I dutifully explained that even if he did have sinusitis, studies show that antibiotics confer little or no benefit on patients with uncomplicated sinusitis. In fact, the best things for sinus congestion/sinusitis are topical decongestants and nasal irrigation. I even printed out a copy of the JAMA study and handed it to him. Then I gave him a couple of squirts of Neo-Synephrine in each nostril. Ten minutes later, he was much less congested and felt much better. He thanked me and promised to go home and use the nasal rinses. That was about 7PM. At 2AM, he shows up again and he is hot under the collar. I walked into the room and asked him what happened. “That Neo-Synephrine makes my blood pressure go too high and I read that those nasal washes can give you brain infections, so I’m not taking them. I haven’t slept yet tonight and I want some Levaquin NOW!” Whoa. I told him that Levaquin wouldn’t help and that I wasn’t going to prescribe it for him. I started to mention that he could use sterile water in the nasal irrigation and try some Benadryl for his congestion/sleep problems, but he interrupted me. “Well then, this was a complete waste of time.” And with that he got up and walked out of the door. Or at least he tried to walk out the door. Only problem is that the doors are locked and patients have to be buzzed in and out of the department. When you’re angry, there isn’t an exception to that rule. He went to the regular exit, tried to open the door, pounded it a couple of times and walked back in the department toward the ambulance bay. People ran after him calling “Sir! Sir! This way, sir! Wait!” He would have none of it. He got to the ambulance bay doors and tried to pull them open with his bare hands. Nope. You have to use a button to open those, too. Then he started shaking the doors. Nope. They still won’t open. We have cameras all over the place, so while he’s freaking out and people are trying to help him, everyone else is watching his antics in the camera and admiring his technique. It’s like a new reality TV series. Then the patient makes one final mighty effort to pull the ambulance bay doors apart. And in the camera he looks just like an angry mime straining against an immovable object. His body shakes ever so slightly. His face gets red. Then … the doors open. Waaait a minute. We looked across the nurse’s station to the control panel. The respiratory tech stood there smiling. “Hey, he was going to break the door if he kept it up.” And with a one-finger salute, the patient stormed out of the emergency department and into ...

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Government Safety

Remember how the government health care wonks at the CDC thought random HIV testing in the emergency department would be such a great idea? Things didn’t quite turn out that way in France. A study in France published in the Archives of Internal Medicine showed that out of 138,000 emergency department visits, 21,000 patients were offered testing and 12,754 actually received testing. Out of those tested … drum roll … a rocking 18 patients received a new diagnosis of HIV. That’s 0.14%. Or .1400000000% if you want to thumb your nose at JCAHO. But wait … that’s not all! Of those 18 patients, most were in high-risk groups, had previously been tested for HIV, and were in late stages of the disease. In other words, the patients probably knew that they had HIV before the testing and the docs probably could have told them they had a high probability of having HIV before doing the test. An HIV test costs $200. Multiply $200 times 12,754 tests and you get $2.5 million spent on testing alone. Then throw in all the wasted nursing and lab time performing the testing instead of providing medical care. That money could provide a whole lot of childhood immunizations. Oh, and while you’re at it, screen every patient for domestic violence, tuberculosis, substance abuse, heart disease; type everything into a computer so we can measure how quick you’re performing your tasks; see more patients with less resources and higher patient loads; make sure you wash your hands 100 times per day (which would require roughly 1/5 of your entire 8 hour shift to do so); fill out all the other ancillary paperwork involved in creating a safe work environment; and do anything else we think might make people safe but haven’t proven yet. Got all that? But studies cited by the CDC in the US show that the rate of new diagnosis for patients at hospitals in Los Angeles, Oakland, and New York was between 0.8 and 1.5%. Does that mean that patients in those areas have ten times as much risky behavior as patients in France? Ten times the drug use? Ten times the unprotected sex? Maybe it’s just those French people creating false data trying to make the CDC look bad. Every patient entering our rural hospital’s obstetrical ward has to either consent to testing for HIV or has to sign a refusal. So far, we’re batting .000 in catching those early asymptomatic cases of HIV. Cost effective and medically necessary health care. These can be the only result of “safety” directives imposed by government agencies.  Kind of like a directive to perform blood cultures before instituting treatment for pneumonia. Oh, wait, I don’t recall seeing any scientific evidence showing the benefit of that directive, either. Policymakers wonder why health care costs and delays in care are skyrocketing? Its own mandates are the rocket fuel.

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Got emphysema, asthma, arthritis, or inflammatory bowel disease? Eat broccoli.

I was forwarded an article that seems boring, but had an interesting catch to it. You  may not have known this, but denitrosylation of HDAC2 by targeting Nrf2 restores glucocorticosteroid sensitivity in macrophages from COPD patients. The study showed that in some forms of chronic inflammatory diseases, such as COPD/emphysema, acute respiratory distress syndrome, asthma, rheumatoid arthritis, and inflammatory bowel disease, a chemical reaction within a transcription factor called NRF2 within the cells causes them to be less sensitive to steroid therapy. When study patients with COPD were given either glutathione or sulforaphane, the chemical reaction was reversed and macrophages within the alveoli of the lungs became significantly more responsive to steroids. One food that is high in both glutathione and sulforaphane is … broccoli. Did a little extra research on the internet and found that glutathione is also contained in asparagus, potatoes and many green leafy vegetables and that sulforaphane is also contained in cabbage, cauliflower, bok choi, and those same green leafy vegetables. And … one of the things that depletes glutathione in the body is Tylenol. Also ran across a study in 2009 showing that the Nrf2 factor also plays a role in Helicobacter pylori infections and that ingestion of broccoli sprouts decreased byproducts of H. pylori infection by 40%. Makes me wonder whether these chronic inflammatory diseases may have some type of bacteriologic basis. Now they just have to do a study to find out many people would rather have COPD exacerbations than eat broccoli or green leafy vegetables every day.

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Dangerous Medications for Kids

From an eMedHome.com “Clinical Pearl” Medications which, when taken even in small amounts, can have significant adverse effects on young children. Camphor, which is contained in many OTC products such as vapor rubs and Tiger Balm Quinine, such as in some cardiac medications and in Placquenil which is used to treat lupus. TriCyclic Antidepressants such as Elavil Oral Hypoglycemics, such as diabetic medications glipizide and gluburide Calcium Channel Blockers, which are fairly common blood pressure medications    Methyl Salicylate, found in limaments such as Ben-Gay and as an artificial flavoring in peppermint, spearmint, wintergreeen (think of Life Savers and Altoids) Theophylline, an asthma medication which has fallen out of favor in the US.     Imidazolines, which are contained in the blood pressure medicine clonidine, but which can also be found in over the counter medications such as Visine and Afrin  Lomotil, a medicine for severe persistent diarrhea. Toxic Alcohols – such as methanol which is found in many paint removers/varnishes and which is metabolized to fomraldehyde and formic acid in the system. Ethylene glycol is also another toxic alcohol found in antifreeze and de-icing products. If Poison Control Centers close under nationwide budget cuts, information like this (including treatment options) will be less availble.

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