Archives for June 2007

Happy Birthday Dr. Schwab

It Seems Like a Year

Well, as of today it’s been a year since I began this blog.

If you have a moment, you might go and congratulate him in his comments.

What’s a server crash look like?


In case you wondered.

ED Karma

I’ve written before about the Dirty Words of the ED, and now I can add another, based on tonights’ experience.

I and my scribe trainee and trainer were exactly one patient from going home early, so I said “Great, we’ll leave early and I’ll get to have dinner with my family”. At that exact moment on of the hospitalists walked up and said “you know that patient…needs an LP”.

Okay. I can see why he’d want it, and that won’t add much time to my departure, and I’m all about the patient care. Get the LP setup ordered, go to suture the was-last patient. While suturing, the patient gets sweaty, rubs chest, says ‘I’m not feeling so good’, and the EKG showing the heart block and heart rate in the 30’s told me this was probably more than a pain reaction from the suturing.

So, patients cared for, and another dinner missed. Oh, and either ‘leave early’ or ‘dinner with family’ are now verboten. I just need to trial them, to warn others.

AMA to "Actively Oppose" some P4P

A little more of this, and I’ll reconsider my no-membership status:

CHICAGO, June 27 — The American Medical Association wants third-party payers to put the brakes on pay-for-performance initiatives until there is evidence that such plans benefit patients.

Moreover, after five hours of debate — often over the addition or deletion of a single word — the AMA’s House of Delegates said that it will “actively oppose” any pay-for-performance programs that do not meet the AMA’s five pay-for-performance principles.

Now, follow through. Please.

via DB.

Change of Shift

Change of Shift begins year two of operation:  Change of Shift At NursingLink –

The Examining Room of Dr. Charles: Adieu

The Examining Room of Dr. Charles
I’m going to take a break from blogging.The Examining Room has been going for almost 3 years. It has been a wonderful experience for me. I’ve met great people, been challenged intellectually, and have had an audience for that bit of creativity still left in me that survived running the gauntlet of medical training.

…The main reason I am taking a break, perhaps a long break, is that my life, like yours, only allows me a finite amount of time for pursuing an avocation. I’d like to try to work on a book. It’s a story you might read one day, or it might simply rest on my bookshelf, unpublished. But it is the writing of the thing that I feel passionate about. Wish me luck.

Thank you, Dr. Charles, for all the excellent free entertainment all these years. Blogging is, after all, a hobby for us in the MedBlog world and hobbies take time, come, and go. You have a writing talent well beyond mortal bloggers, and I hope you do write that book, even if it is about tomatoes.

And come back if you want.  We’d love it.

MedBlogs Grand Rounds 3:40

Wandering Visitor: Welcome to Grand Rounds!
Welcome to Grand Rounds!

Nice Grand Rounds (though I don’t think she actually read my submission for content…)

Nursing Home MAR’s sent to the ED with all times removed: A new and horrible trend

There is a new, intentional and horrible trend in nursing home transfers to the ED, and it’s not the patients. It’s the records that come with them, or more specifically those that don’t.  Allow me to explain.

The patient is sent with a chief complaint, a lot of weeks-to-month-old labs and a medication list, but all the administration times have been cut off from their typed MAR’s. (MAR stands for Medication Administration Record, and is the only written record of which patient got what medicine, when). Got that? A patient sent from a nursing home comes into the ED with a list of their medications, but the list has the times and dates of administration removed. Intentionally. They come in with little strips of paper with the medication names and doses, but the administration times are on the paper that wasn’t sent. That’s not an accident. Definitely not.

When they’re my patients I now ask for a faxing of the patient’s MAR from the nursing home with the removed information included, because it is, you know, part of the medical record, and may well be useful in the diagnosis and treatment of the patient. A patient often sent in with “AMS” (altered mental status) as the one-line explanation for the transfer, and the patient is on several (usually more than a dozen) medications, at least a third of which could cause an altered mental status. It would, in that case, be nice to know if they got their regular, let alone their PRN (as needed) sedative(s), as well as all their other medications.

The kicker is, since I cannot determine when their medications were administered (because the times were cut off of the copies sent to the ED), a lot of very useful information is now denied to me, the ED physician, and then most likely to the admitting team, since none of us can say who got what medication, and cannot account for their altered mental status. (I’m using AMS as the example here, but there are other complaints that could be medication related).

This intentional removal has happened often enough ( from different nursing homes and at different ED’s) that it’s clearly part of an organized effort on the part of Nursing Homes. I’m at a loss to think of a single innocent reason why this practice would have started. When I’ve called personally to have the information faxed (for patient care, the reason they sent the patient to the ED) the Nursing Home nurses routinely say that “It’s policy”, and then sometimes send the information, and sometimes they don’t.

This is outrageous. A chronically ill patient is sent to a higher level of care for an acute problem, and without a complete information base; but not just that, information crucial to the care of the patient that’s being intentionally withheld.

It is a situation that makes me, frankly, nuts. When did intentionally withholding critical patient care information become acceptable? Seriously, have these people not learned from history? The coverup is always, always worse than the crime, and is looked upon less favorably and punished more severely that any original offense. You could ask Nixon, but he’s dead.

Send me all the info you have, and our patient will live or die based on their problem(s); withhold information I need, and it’s on you, Nursing Home nurses.

(Nursing homes that engage in this awful practice, beware: I now document ‘Patient sent to ED with MAR with times removed’ on my charts, and you’re kidding yourselves if you think this kind of obfuscation will get you out of a medicolegal jam.  Were I a plaintiff’s attorney (and I’m not) I’d be at least somewhat interested in what was withheld, by whom, and why. Still seem like a good practice?).

M.D.O.D.: Whither the Generalist?

M.D.O.D.: Whither the Generalist?

Read, and wonder.  A terrific post.

Don’t have sex with your patients.

Apologies to KevinMD for usurping his ‘doctors gone wild’ series…

I thought this had been covered, but at least one more doc didn’t get the memo:

Doctor suspended over sex sessions in emergency wardThe Daily Mail logo


A hospital doctor who had sex with a former patient while he was on duty in the casualty department has been suspended for 12 months

Dr Timothy Davey, 46, was removed from his £60,000-a-year job after he admitted he was “sexually intimate” with the woman when he was supposed to be working.

The married father of two had treated the woman for a knee injury and then struck up a relationship with her after sending her flirtatious text messages.

A career probably ruined, a marriage most likely completely sundered.  And possible licensure actions!  A trifecta!

West Nile, June 12, 2007

Remember the “West Nile is going to kill us all” scare?  As predicted, it’s gone through its epidemic spread, and now is into its pandemic stage:


Map of West Nile Virus activity

6 human cases this year.  Keep wearing your DEET, though.

Congressional Quarterly: ERs are “Biggest Crisis in American Healthcare”

Congress hears from those who prepared last June’s IOM report on the impending ED disaster:

June 22, 2007 – 7:24 p.m.

Emergency Rooms Labeled ‘Biggest Crisis in American Health Care’

Physicians told a House hearing Friday that the nation’s emergency medical care departments are overwhelmed, understaffed, underfunded and unready to take on the type of patient surge that could come with a major natural disaster or terrorist attack.

Despite numerous reports highlighting conditions such as patients being boarded in ER departments waiting for rooms elsewhere in the hospital or ambulances diverted to other facilities — creating treatment delays that have led to patients’ deaths — federal agencies charged with overseeing the nation’s emergency health care system have done little to ease the burden, witnesses told the House Oversight and Government Reform Committee.

“While the demands on emergency and trauma care have grown dramatically, the capacity to handle such demands has not kept pace,” said C. William Schwab, who heads the University of Pennsylvania Medical Center’s Trauma and Surgical Division. Schwab, who helped compile the Institute of Medicine’s report released last June detailing key problems with ER departments and recommendations to fix them, noted that there has been little response from Washington.

Read the whole article to get the flavor. The good news? At least one congressman is ticked at HHS for not acting strongly enough:

Committee member

Elijah E. Cummings, D-Md., who chaired the hearing, said the Department of Health and Human Services (HHS) “appears to be ignoring the mounting emergency care crisis” despite the billions of dollars Congress has appropriated for biodefense and pandemic preparedness. Witnesses said the funding had not relieved any of the burdens in their emergency care departments, and Cummings said HHS has “not made a serious effort to identify the scope of the problem and which communities are most affected.” Cummings was clearly irritated that Leslie Norwalk, acting administrator for the Centers for Medicare and Medicaid Services, did not accept the committee’s June 14 invitation to testify at the hearing. Of the 115 million emergency room visits in 2005, more than 40 percent were covered by CMS programs such as Medicare, Medicaid or the State Children’s Health Insurance Program.

Read the rest for the denoument (Warning: mentions Rep. Henry Waxman). So, Congress is awakening to the idea that the ED’s are being over-run. Most likely that’s good news.

Coffee Maker update

Today it died. The coffee maker I bought December 20th, 2006. The heating element expired.

It gave good service, and ran 24/7 for seven months, which is a lot longer than I thought it would.

Tomorrow, a new one.

Primary Care Access, the ED, and 1972

Stimulated by an entry over at Medical Humanities, what started as a comment took up too much space, so it goes here, instead:

There are many who believe with total sincerity that more primary care offices will alleviate the burden on ED’s; this is hamstrung by the horrid pay primary care docs get, so that currently they have to operate like airlines, and overbook. Too many empty seats/open appointments = financial disaster. There isn’t a lot more money coming to primary care in the near future. So, ED = safety valve.

That’s one of the big reasons why a lot of my patients in the ED have insurance and a primary doctor, but they (not unreasonably) believe their pneumonia symptoms shouldn’t have to wait 2 weeks for the next appointment. They come to the ED, they wait, but if willing to wait they’ll get seen. (If minor care clinics would bill insurance, a LOT of those people would flee to them, but the minor care owners have seen what bargaining with the crocodile has done for hospitals and conventional primary care, and want nothing to do with them).

To me, one of the biggest reasons ED volume continues to grow is that office medicine is still practiced like it’s 1972: wait a week or three for your appointment, take this chit to the lab, they’ll draw your blood, come back in a week and we’ll review your tests, then order some more studies if we need them. (And it’s that way for doctors, too: I had a stress test done about 6 months ago (I’m just fine, thanks) but I had to call six times over 10 days to get the result, and that was after waiting the four days they said it’d take to have it read, which was utterly ridiculous). Compare that to the ER: tests drawn and resulted in about 2 hours, decisions made on the tests; subsequent emergency tests readily available, usually around the clock. Americans (and not just Americans) are voting with their feet and choosing the ED, and not because it’s the shiniest place with smiling people, they come because we’re ready to see them around the clock, and we’re capable.

As for the PCP’s: there are about three who get bent out of shape when their patients go to the ED without telling them, and they are very good, old-school docs. They come in and see their patients in the ED, and admit themselves if needed. The rest are resigned to the current system that penalizes the office doc for admitting their patient but pays the hospitalist to admit the same patient they don’t know from Adam.

And, despite how screwed up the system is (and it is), a lot of terrific people work tirelessly to keep it moving, to keep helping patients. Frankly, it’s a wonder it still works at all. But it’s time we had a look at patient expectations about waits (most of which are reasonable concerns) and start moving the system to accommodate those concerns outside the ED. Without breaking the bank.

GruntDoc: Rated R??

Or, at least that’s what I got when I ran this blog through a site that examines the content and assigns a ‘movie rating’:

That’s not what I though it’d get, and is biased not by dirty words but by words like ‘pain, dead, dangerous and knife’ (which all go together, interestingly enough).For the record, I think this is a PG blog at worst, but I thought this was funny enough to mention.In case you were wondering:

Why is is that those with an NC-17 rating will get more hits from this than the G rated ones?