Archives for June 2007

Musings of a Highly Trained Monkey: This one’s for GruntDoc

Musings of a Highly Trained Monkey: This one’s for GruntDoc

It’s a visual.  Enjoy.

Forged Scripts

via KevinMD, this advice on dealing with them from OnThePharm:

General Prescription PadsEveryone has their own preferred method of dealing with forged prescriptions. Ryan at EclecticEsoteric recently asked what I would do. It so happens that Andrew at PharmCountry has a related post, so it seems an opportune time…

When you’ve got a forged or altered prescription, there are two basic things you SHOULD do.

1) Contact the prescriber. Verify that it has been forged or altered.
2) Initiate a PharmAlert, the details of which can be obtained by contacting your state’s board of pharmacy. I believe this is how such an alert is usually initiated anyway — I’d say “always” but I haven’t worked in every state, so that’s impossible for me to know.

Prescription alteration and outright forgery comes up sometimes in the ED, and I’ve had several kinds happen.

Right after I moved to this job (about 5 years ago) I started getting calls from pharmacies to verify called-in prescriptions for phenergan with codeine. This immediately raised my eyebrows, as I prescribe that maybe 4 times a year, and we don’t typically call in prescriptions. All the pharmacies I called back said the caller had the rap down, knew exactly what to say, had my DEA, etc.

Interestingly, the pharmacists had a hunch, despite the good call-in rap, that there was something fishy so they called to verify (experience counts). I thanked them all, then asked they call the cops if someone actually showed up to pick it up, as I’d had a bunch of these calls. I never heard more about it, and it tapered off over about 3 weeks. The caller no doubt just got someone else’s’ DEA number. (And what a weird drug to abuse…)

The big winner in this category goes, though, to this exchange:

Charge Nurse: Gruntdoc, did you write a prescription for Marinol to a patient recently?

Me: No, why?

CN: Well, there’s a parole officer on the phone who has a parolee whose drug screen came back positive, but has a prescription for Marinol on one of our pads with your name on it. As an excuse.

Me: Heh. Nope, I’ve literally never written a prescription for marinol in my life.

This was relayed, and in short order I got a fax of the prescription, and it was fairly good: the writing style looked hurriedly-efficient, there was a written-out quantity, the Sig line was what you’d expect. My signature wasn’t anywhere close, and the really interesting part was the DEA number didn’t follow one of the really basic tenets of how they’re encoded. Any pharmacist would have picked it up in less than a second, so this was never presented to be filled, it was written to attempt to stay out of jail.

CN: They wanted you to type out a letter, on official letterhead whether or not this is your prescription. I told them we were too busy for that, so they agreed on a hand-written response.

Me: (Again noting our CN’s are very smart) Thanks!

So, some scribbles and my real signature later, off went my reply. I never heard any more about it, though I wonder if it’s a crime to carry around a forged prescription if it’s never presented to fill a medication (I doubt it). It probably is a crime to use a forged script to stay out of jail on a probation violation, but then they wouldn’t need any kind of forgery charge, I’d think, they’ve got all the evidence they need in the little jar.

And, it’s 2007! Why are we hand writing things on little slips of paper and giving them to patients to then literally hand-carry to pharmacies? I’m going to gripe my head off when the EMR comes to my ED, but if it comes with an automated way to transmit scripts to pharmacies I’ll gripe a little less loudly.

Some background on prescription fraud, from a defense-attorney site (good info).

MedBlogs Grand Rounds 3:39

from CodeBlog:

Welcome to Grand Rounds 3:39! This is my fourth time hosting (The second four-time hoster!) and to commemorate the occasion, I’ve decided to unleash Henrietta the Healthcare Worker, my inner advice columnist. Enjoy the links!

Another very imaginative Grand Rounds, from the only other four-time hoster (hostess?)!

BBC NEWS | Health | Coffee ‘could prevent eye tremor’

BBC NEWS | Health | Coffee ‘could prevent eye tremor’

Coffee ‘could prevent eye tremor’

People who drank coffee had a lower risk of blepharospasm
Drinking coffee protects against an eyelid spasm that can lead to blindness, a study suggests.Italian researchers looked at the coffee drinking and smoking habits of 166 people with blepharospasm.

Sufferers have uncontrollable twitching of the eyelid which, in extreme cases, stops them being able to see.

One or two cups of coffee a day seemed to reduce the risk of the condition, the team reported in the Journal of Neurology, Neurosurgery and Psychiatry.

Again, coffee saves.  What can’t it do?

Calling All Doctors: Casting Call

Doctors are sought to appear in a documentary about docs. This arrived by email, and I have her consent to reproduce it here:

I am co-producing a documentary with a colleague of mine, Dr. Ryan Flesher, board certified in emergency medicine. I am a licensed Social Worker from the healthcare industry who never fully understood, until recently, the impact and impossible demands made upon our doctors.

I now straddle two worlds: a view from the patient’s side and a view from the doctor’s side. It has been both an enlightening and disheartening experience. After all that I have learned from my research for this film – clearly, it is time that we elicit compassion for our physicians.

The physicians’ view is rarely talked about. If I had not researched, interviewed or discovered what doctors are experiencing, I would never have known. The film’s producer, Dr. Flesher is discouraged by the business and politice, not the art, of medicine for a myriad of reasons, all of which we will be highlighting in our documentary. He could quietly walk away from medicine, leave it all behind. But he is not doing that. Instead, he is doing something purposeful with his experience by creating a film that will give voice to physicians on what needs to be said. This film is a first of its kind.

[Read more…]

Smells of the ED

I turned the corner the other night, and smelled one of the unique odors that makes EM special: urine and peppermint.

Peppermint oil is very frequently used, and is a decent cover-up smell, but urine is one of those all-pervasive olfactory treats that means you’re in the hospital.

Alleys don’t smell like peppermint.

ACEP Bookstore may need a calendar

It’s 2007. Time to update the procedures…

From: customerservice@acep.org
Subject: ACEP Bookstore Order Confirmation
Date: June 16, 2007 1:28:16 AM CDT
To: (me)

Thank you for your order.

Your order has been submitted to ACEP Customer Service for final processing and shipping. Most orders are shipped within 2 business days. Delivery for all orders is dependent on product availability. If your order is delayed, we will notify you by postcard as soon as possible to determine the proper remedy. If you have any questions or comments, please send an email to customerservice@acep.org or call during business hours at…

Hmm, they have my email address, but they’ll send me a postcard if it’s not in stock? Goofy.

More Dead Blogs

As I have no life, I went through my blogroll this evening and unfortunately added several blogs to the “Dead” blogroll. Generally, no posts in more than 3 months, or taking your blog private makes it a functionally dead blog.

It’s amazing to me how many really good bloggers just get bored, or tired, or decide it’s not for them. (If I’ve added a blog in error, please let me know).

  • Ace of Trump
  • ChaiTeaLatte
  • Capsules
  • code:theWebSocket (that one hurts)
  • Doctor
  • Dr. Dork
  • Dr. Hebert’s Medical Gumbo
  • Flea (no explanation needed)
  • richard[Winters]md (he who got me into this)
  • Trench Doc
  • Dr. Tony
  • Health Care BS
  • Medical Matters.org (Sen Bill Frists’ blog)
  • Mr. Code Brown
  • Neo Nurse Chic
  • Push Fluids
  • Scared to Health
  • Subaqua Sternal Rubs
  • Tales of an MD/PhD Student
  • the MUSC Tiger (shifted blogs)
  • Women, Fire and Dangerous Things

21 20 19 added (and two removed!). (For their URL’s, please see the sidebar. It got depressing after a while so I’m not adding the links here).

Funky Chandelier

Expectations, or Letting People Down

One of the big joys of Emergency Medicine is helping patients. It’s truly enjoyable to suture a laceration, to reduce the dislocation, to give solace to the suffering (usually pain medicine, but not always, sometimes it’s a hand to hold). These are almost always patients who present with a sudden-onset problem, be it trauma or bowel-obstruction, and that’s why I’m there (and why my colleagues are there, as well). Patient faces begin with apprehension, and are often back to normal when they leave (and some leave with a satisfied look I take as the reflection of a job well done).

Then there are those patients I cannot help but let down. They come to me with vague complaints that have gone on for years, a pain they cannot describe or can describe too well, a discomfort that nags, a rash that won’t wane, a twitch that won’t stop or a balance that won’t start. They have seen specialists too numerous to mention, have tried medicines/potions and remedies that run the gamut of medical experience, they’ve done their exercises and, still, they want for a remedy.

I have finally learned that there are some patients I probably won’t be able to help medically and that it’s actually cruel to let them think otherwise. For instance, the patient with the low back pain that’s been to seven neurosurgeons (had three operations), been to the Mayo Clinic and to innumerable chiropractors, who looks at me and says “I need to get better”, what’s causing the back pain? Realistically, what can I offer that a myriad of specialists couldn’t? Oh, I’ll do the entire LBP exam, do a history looking for zebras and other horrible causes of back pain, and occasionally I’ll want to do some tests to rule out an emergency.

I used to leave the room with the generic “We’ll get you some pain medication and do some tests”, and then return to the room after some time, when the tests are back, and go through a prolonged ‘isn’t there anything you can do’ session with the patient and their family. They know there’s not, really, but I left that door open, and it’s at least partly my fault.

So now I let them down early. Yes it’s disappointing but I think it’s healthier for them (and me), in the long run. “You’ve had this for x years, you’ve seen about a dozen specialists; as a general rule, if a bunch of specialists cannot figure it out in their offices with all the studies, tests, etc. we’re unlikely to in the ER” is now my general start-of-the-letdown, and even the least reasonable from an expectations standpoint seem to get it: I’ll try, but it’s unlikely. Now the patient doesn’t spend the next hour-plus building up hopes to be dashed-yet-again. As memory serves I’ve never made the terrific diagnosis for the unfixable complaint, and it’s not for lack of trying. Some things I cannot change.

It’s disappointing for me, too. I’d much rather say ‘here’s the diagnosis, and the cure’, but it doesn’t work that way in real life. Maybe some of the letdown is for me. Okay, no maybe about it.

We’re pretty good in the ED with acute problems, less so with the chronic ones, and dismal with the ones nobody can solve. Sometimes expectation management is the best we can do, for everyone.

(General disclaimer: I do a real history, a real physical exam, and listen to my patients. I don’t prejudge anyone, and the above applies only at the very very end of the patient interaction, and not before.)

Kevin, M.D. – Medical Weblog: Healthcare 100

Maybe I should quit blogging, if I can’t break into the top 100-150 medical blogs…

Kevin, M.D. – Medical Weblog: Healthcare 100
Healthcare 100
Speaking of Power Lists, eDrugSearch comes up with a Top 100 list of health and medicine blogs, based mostly on objective measures such as Google PageRank, Bloglines Subscribers and Technorati Authority Ranking.

Yeah, I know, it depends on the scoring system used, and I didn’t score well here.  Congrats to all the fine blogs listed!

Oh well, I have my eight readers. That’s enough for today.

Nurse Ratched’s Place: Change of Shift: Volume 1, Number 26

Nurse Ratched’s Place: Change of Shift: Volume 1, Number 26

Welcome to the anniversary edition of Change of Shift.

Happy Anniversary!

Yes, we know.

The server that runs this blog crashed, hard and without warning last night. The host had backups for the site through the 2nd, so that’s what’s on the page now.

I have a backup from the 11th, which is the best we can do, at least for now. It should be back up and running tomorrow, but anything after the 11th will be lost, so we’ll see.

Oh, and this post will probably disappear also, as the updates happen. I’ll re-explain when it’s back to normal.

Update 6-14: Thanks to Brian, the backup has been restored. I’m missing the post about a new mac powerbook (and the comments),(thanks again to Brian) and a photo. So, not too much lost. (Hint: do backups of your blog).

MedBlogs Grand Rounds 3:38

Grand Rounds 3.38 Immediate Release – Blogs – Revolution Health

Welcome to the latest round up of the best of the healthcare blogosphere. Today it is my pleasure to offer you your weekly dose of Grand Rounds, optimized for your state of mind. I believe that there are two basic types of blog readers, and so you’re getting Grand Rounds 2 ways (with a dash of cartoons thrown in for extra “feel good” measure):

A very imaginative (and easy to read) way to do Grand Rounds. Kudos!

Cult of the Mac adds another (sorta)

All, I am getting a Mac powerbook sometime this week. I have had a Mac-mini, and while it’s been intriguing (and stable) the power of it was limited, so it was relegated to second-banana status. Ultimately, that means I haven’t done much in the World-o-Jobs.

Nor will I be completely switching; I have way too much PC gear / software / experience to trash it all (and couldn’t afford to if I wanted).

But, I know there are those among my seven readers who are very familiar with Macs, and are just dying to help me out with the ‘what should GruntDoc add’ to my new Mac book. I will use it for blogging, surfing, the occasional powerpointy talk, and will probably dabble with pictures and some video more than I have been. I do need to be able to get into Windows to run some apps there. I have “Switching to the Mac, the Missing Manual“, and it’s good reading.

So, what should I add, preferably freeware that’s not bleeding edge? Your comments are officially solicited.

PS: I now have a Prius and will soon have a Mac. This does not mean I’ll be getting a goatee, wearing sandals and going vegan. Just so we’re clear on that.

(All the original comments went ‘poof’ in the Great Server Disaster of ’07; feel free to re-comment, or ignore it, whichever.)

First impression: strange to get a new box from Apple, that then immediately needs 100mb of updates.
Second: Backlit keyboard is definitely a selling point; I thought I’d like it, and I do.
Third: iWork preinstalled (paid for) wants me to enter my serial number? Isn’t that why we buy it preinstalled, so it Just Works? Dumb. Gotta go find a SN.
Fourth: It took some reading, but in the ‘system preferences’ there’s a tweak to make the touchpad act like it has a right mouse button, which is terrific for a switcher.
Fifth: Firefox works perfectly well. (I really enjoy Opera, but like the Firefox extension that keeps the bookmarks synced enough to prefer it).
Sixth: no ‘delete’ button that means delete? The delete button is where the backspace belongs, and that’s what it does. Fn-delete does the same thing, but seems silly.
Seventh: Battery life is fair, at best.  Not up to Dell standards.  Really.