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Tag Archives: Policy

Transporting Morbidly Obese Patients

Obese Woman Dragged From Home, Hauled Away After Death A 750 pound woman dies at home. According to police and the coroner’s office, there is no truck big enough to transport her to the morgue, so police call the towing company, they drag her out of her apartment on a mattress and load her onto a pickup truck to bring her to the morgue. According to witnesses, the tow truck drivers threw a piece of carpet over her instead of a sheet. I’m assuming the reason for this is because not too many tow truck drivers or coroners carry extra large clean sheets in the backs of their vehicles, but that is purely speculation on my part. Family members and neighbors were appalled. It was “like putting a cow up there,” said the deceased’s boyfriend. They don’t treat [dead dogs] that way,” stated a neighbor. Supposedly the fire department has equipment that will handle patients up to 1000 pounds, but no one knew that. Assuming that the fire department didn’t have the equipment available, what would the family have done to get the patient to the morgue? If people allow themselves to get so obese that traditional transport mechanisms won’t work, then what duties should providers have? [Thanks to Alexander for the link] UPDATE JUNE 8, 2009 Amazing how posts take on a life of their own. When I originally posted this, I did not intend for it to morph into a discussion of “political correctness,” but also agree that being “PC” has gone too far. Many thoughtful comments in this regard. My original intent was to show how the medical system said “no.” “No we can’t transport your body in the coroner’s vehicle because you’re too large.” Patients need to understand that sometimes there are consequences to their actions. In some cases, providers will have to get the job done with what’s available to us, and you may not be happy with the results. In other cases, patients may not be able to receive appropriate treatment. What happens if a 750 pound person passes out on the second floor apartment and there is no elevator? What if it happens in a rural location and there are not enough volunteer EMTs to lift the patient? Will providers get sanctioned for saying “we can’t help you”? As Shadowfax notes, there is an entire industry catering to the morbidly obese patients. We have “big boy” beds. Stretchers are now guaranteed to hold more than 500 pounds. But there are also limits to diagnostic equipment. MRI machines might not accommodate a patient’s girth. CT scan gurneys “only” hold 350 pounds. So what happens if we suspect a morbidly obese patient has a pulmonary embolism, but we can’t do the diagnostic testing to confirm the diagnosis? What if we need to do a CT scan for a morbidly obese patient who has a head injury? And what’s going to happen in the future medical delivery systems if there is not as much of an incentive to purchase expensive equipment necessary to cater to the morbidly obese population … or an incentive to risk the increased likelihood of bad medical outcomes in providing medical care?

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Healthcare Policy Roundup – June 2, 2009

EMTs – “we bring the emergency room to your living room.” Cool article that makes you think about how much these guys and gals are underappreciated. Want to get first hand experience of what it’s like in the ED? Try the newest game for the Wii and DS – Hysteria Hospital: Emergency Ward. Players “will have to reach desperate patients and demanding doctors within a set period of time. The frenzy inside the hospital will increase as the game progresses with more and more demanding patients desperate to be cured!” And that’s a challenge … how? We do it every day. According to a report by Families USA, insured families pay a “hidden tax” of more than $1017 to pay for health care of the uninsured. That hidden tax isn’t cutting it in Washington State, though. Washington’s legislature just enacted $1 billion in health care spending cuts that will leave almost 40,000 additional people without care, including elderly patients, the disabled, children who need vaccinations, and those who need drug treatment. Back to problems with emergency care in the Canadian system. Snooore … right? But look at the similarities to the US system. There is a shortage of primary care physicians in “almost every community in Ontario.” Many patients are now crowding into the emergency departments “for care that they would normally get from their family doctors.” What’s the Canadian government doing about it? They’re throwing more money into the emergency care system to “add physician assistants to emergency rooms” (i.e. encouraging more people to come to the emergency department for routine care); “improve information technology” (i.e. implement EMRs that decrease productivity and decrease patient throughput); and promote health-care alternatives to the emergency room (i.e. doing exactly what the University of Chicago got blasted for doing in the media). Be interesting to see how this experiment plays out. Have an emergency in Canada? “Don’t bring a book, bring a library.” The average stay in a Montreal emergency departments has decreased to only 19 hours and 48 minutes. At Maisonneuve-Rosemont Hospital, the average stay is 34 hours 18 minutes. But the care is free, right? The medical system in South Africa is also collapsing. Public sector physicians are working more than 80 hours per month overtime and government pay is less than adequate. Experienced specialists are “leaving the public sector and moving to the private, leaving very few top senior specialists to continue training us and improving the standards of care in South Africa.” The public is stating that physicians should choose to study medicine “because of the greater cause — to help people” and that the physicians should not be fighting for more money. In other words, the public expects that some of the brightest students in the country pay for 8 years of education, then work at less than minimum wage during their internship and residency, and go hundreds of thousands of dollars in debt so that they can then treat people for free. Yeah, that will work real well. Flash forward 10-15 years and this public/private battle is what I foresee happening in the US. Aussie courts don’t put up with any crap. A patient went to the emergency department there complaining of back pain, yelled at the staff after not being seen for several hours, then called the Australian equivalent of “911” four times demanding that police come to the hospital to intervene on his behalf. The last time he called, he threatened to kill the 911 operator. He was arrested and fined $1500. The judge stated that “The hospital staff have a difficult enough job to ...

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Remember Esmin Green? You can read my previous post on her case here, but she’s the patient who collapsed in the waiting room of Kings County Hospital in New York and who was ignored by the staff for an hour before being pronounced dead. Later the coroner determined that she died from a blood clot to her lungs – something that would have caused her death regardless of the treatment she received. On Wednesday, New York City agreed to pay Ms. Green’s estranged daughter $2 million to settle a $25 million lawsuit that the daughter filed against the hospital. The plaintiff’s attorney, Sanford Rubenstein stated that the settlement was “fair and reasonable.” Let’s see … he makes 33% of $2 million – or about $666,666.00 – for 8 months’ work in settling a case that couldn’t be proven in court. Sure, I’d call that reasonable. Ms. Green’s daughter, Trecia Harrison, who lives in Jamaica, hadn’t seen her mother for 8 years before the incident. Even though her mother didn’t have a telephone, Ms. Harrison reportedly called her mother “constantly.” Ms. Harrison walks away with $1.3 million. As a result of Ms. Green’s death, the Department of Justice investigated Kings County Hospital and issued a 58 page report about how the conditions in the hospital had become “highly dangerous”. In response, Kings County constructed a new Behavioral Health Center, has added 200 additional staff members, and has reduced the waiting times in the psychiatric emergency department from 27 hours to 8 hours. With NY City tax revenues down $1.38 billion from 2008 and an operating deficit of $3.7 billion in fiscal year 2009 (see page 27), I can’t imagine that the significant increases in expenditures at Kings County will be long-lived. Hospitals struggle to stay afloat while providing increasing amounts of uncompensated care. Estranged family members earn multimillion dollar windfalls for bad patient outcomes that, “to a reasonable degree of medical certainty” were unpreventable. Plaintiff attorney works 10 months on case and earns between $416.66 and $8,333 per hour for doing so (40 weeks of work times 40 hours per week = 1600 hours. Contingency fee of $666,666 for 1600 hours work comes out to $416 per hour. If we assume a typical attorney handles 20 active cases at a time, hourly rate increases to $8,333 per hour). Wonder why our health care system is going bankrupt? See also ERP’s post on the same issue at ER Stories

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Why Rationing of Care Won't Work in the US

I recently read an interesting article by Dick Morris called “Death of U.S. Healthcare” posted on The Hill. Morris was a former adviser to Trent Lott and to Bill Clinton. His opinion is that Obama’s health care reform will cause rationing of medical services and he cites several comparisons between the US and Canadian systems. Another article on The Hill cites President Obama’s promise to provide “basic” health care coverage for everyone. I agree that rationing is going to occur, but there’s at least one thing that will prevent some medical services from being rationed. Let’s use one example. Suppose you want to cut the costs of health care by no longer paying for costly medical care that does not provide a long-term benefit. You assign your employees to perform a “study” on costly medical care. The study done by your employees (kind of like a study on the effectiveness of a medication that is funded by the drug company making the medication) determines that patients older than 90 years of age on dialysis do not show a significant improvement in quality or duration of life. You then create a new medical practice “guideline” that says, based on this medical effectiveness study, dialysis will no longer be an included medical benefit for patients more than 90 years of age. What happens? Some families might pay for the bill for future dialysis out of their own pockets. Some families might just let grandpa die a slow death from his renal failure. Most families will just call “911” and the red taxi with the spinning light on top will come to pick grandpa up at his home and take him to the emergency department. At that time, grandpa will receive thousands of dollars in lab tests to document that he really is in renal failure and that he needs dialysis. If dialysis is necessary, grandpa will receive emergent hemodialysis thanks to EMTALA. He might even need a day or two in the hospital to make sure that he is “stabilized.” Then the red taxi with the spinning light on top will bring grandpa home where he will sit a few more days … until he needs dialysis again. One little phone call and the whole process starts all over again. By excluding preventive care that averts an emergency, the government will create a situation in which the same care becomes more expensive. All grandpa’s family has to do is pick up the phone and hit three little numbers and he’ll get dialysis any time of the day or night. The government will get its wish, though, as it will no longer have to pay for dialyzing nonagenarians. The burden of paying for emergent dialysis will shift from the government to the hospitals. You see, EMTALA requires that hospitals provide stabilizing treatment, but it says nothing about who will pay for the stabilizing treatment. Hospitals will be forced to eat the cost of providing care. As more of the costs are passed on to the hospitals, more and more hospitals will close. Then less medical care, and less emergency medical care will be available for everyone. EMTALA and the numbers 9-1-1 are two reasons why healthcare rationing inherent with socialized medicine will never be a viable alternative in the United States. Rationing will cause cost-shifting which will in turn cause hospitals to close their doors.

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Health Care Policy Roundup 5-19-09

The Dallas Morning News has an article stating that the current Obama plan to reorganize medicine may be a foot in the door to get medical malpractice reform. Based on the number of former plaintiff attorneys in Congress, one commenter doesn’t think so. It seems as if the more that we want to implement electronic medical records, the more that we see how the technology just isn’t ready for prime time. Incorrect information inadvertently entered into or imported into one’s medical record can have long-lasting effects. Because “coding” involves turning a bunch of non-standardized medical conditions into a set of standardized numbers which are easier for computers to recognize and categorize, inaccurate CPT coding can also cause problems with medical treatment and medical insurance. A reader e-mailed me a link about an Australian hospital that actually banned electronic records in their emergency department when the electronic system failed twice in three days. The article also noted how electronic charting was decreasing the productivity of the physicians: More charting = less patient care = “patients put at risk.” Where have I heard that before? An Indiana man gets thrown in jail for five visits to the emergency department in one day. The doctors apparently wouldn’t give him any pain medication on the fourth visit and he became unruly. Police were called, told him to leave and he did so. When he returned for the fifth visit, the po-po threw him in the hoosegow. Before everyone starts remarking about how ED abusers should be arrested, remember that this woman was placed under arrest in the ED and was being transported to a police car when she became unresponsive and died. Doesn’t make for a very strong defense at trial. Sick of all my posts comparing US healthcare to the Canadian system? Here’s a comparison between the US and French systems. Even the French system is running into budget shortfalls and is now starting to pull some pages from the US system. French citizens pay an average of 40% in income taxes compared to an average of 25% in the US. One big problem according to a French physician: “Consumers are too used to the idea that health care should be free. Many people in France would think less about going [to the emergency department] than they would to go to a café.” No matter what country you’re in, health care reform won’t work if consumers have no skin in the game. Dr. Nortin Hadler is deservedly getting a drubbing in the comment section on ABC News after stating that we overtreat medical problems in the US when there are no studies to show that treatments are effective. According to Dr. Hadler, we need to rethink our use of oral hypoglycemics, CABG and angioplasty, screening mammography, and surgery for low back pain. I actually agree with the last one – unless there is cord or nerve root compromise.

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How to get rid of C. diff?

According to this Medscape article, trying to get rid of Clostridium difficile spores by using traditional hand sanitizers won’t cut it. C. difficile spores are everywhere, including tables, curtains, lab coats, scrubs, plants and cut flowers, computer keyboards, bedpans, furniture, toilet seats, linens, telephones, stethoscopes, jewelry, diaper pails, fingernails and physician’s neck ties. The spores themselves aren’t harmful, but when they are ingested, they can transform and cause colitis. C. difficile spores are difficult to eradicate because they secrete a sticky substance allowing them to adhere to surfaces which, in turn, makes them difficult to remove. Think of little beads with a honey coating. In the Medscape article none of the cleansing products – even the soaps – removed more than 90% of C. difficile spores. According to this study, C. difficile can be cultured from the stool of 3% of healthy adults and 80% of healthy infants. This MSNBC article shows that C. difficile is present in 40% of grocery meats. According to this commentary, more than a third of patients in a North Carolina study had community-acquired C. difficile infections (i.e. not the hospital’s fault) and more than half of patients with C. difficile recently used antibiotics. And … one of the quality measures forced upon us by CMS and Hospital Compare requires us to use antibiotics on ALL known or suspected cases of pneumonia within 6 hours of the patient’s arrival. These “quality measures” significantly increase antibiotic use without any improvement in mortality or hospital length of stay. At the same time, they increase the likelihood of C. difficile infections. C. difficile is present in up to 40% of the meat we eat. C. difficile is commonly present in the stool of healthy infants and adults. We can’t completely get rid of C. difficile spores no matter how much we wash. And … for the sake of “quality care,” the government forces us to give many patients unnecessary antibiotics that actually increase the chances that a C. difficile infection will occur. But if C. difficile infections occur in a hospitalized patient, the government won’t pay to treat them because the infections are “never events” and should “never” happen. Go figure.

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