Another reason I like my job

Colleagues I can call on and count on.

Recently I was the 11p doc in my ED (the overnight shift), and I knew what my evening had in store when Colleague/suspect1 said “It’s been slow all day”. Oy.

At 11:03P the charge nurse (who deserves a Medal for her actions that night) said ‘you’re getting a level 1 medical and two level 1 trauma transfers in the next five minutes’, and that was in addition to the waterfall of regular patients who heard the word ‘slow’ and ran like very sick possessed zombies to our ED.

The medical was a great case I would have loved had I had no other duties: CHB, external pacer dependent, and I did the right thing for this patient: I called the procedure doc, and turned that patient’s care over to him (the one who caused this, Colleague1). (I knew what this patient needed, it’s an intubation/cordis/float the pacer/etc, and that’s 20 minutes straight of terrific procedures while letting the department drown). He did as well as you’d think. Maybe better than I would have done.

The other colleague star was Golleague2, the 9P, who never peeped that I wasn’t sending him home, or really even taking his workups. In fact, toward the end of the night he did a lac or two for me, and I kept Colleague1 busy until 3 with procedures. Terrific to have people you can count on.

This isn’t about me, or even these two great colleagues (though I thank both of you profusely), it’s really about all of us. Giving means getting, and I and our mutual patients got the best that night, and get it when we work and play well together.

It’s a great place to work. Thanks to you all.

ED patient: word to the wise

If your driver has a personality disorder, it will reflect on you. It’s unavoidable.

please ask them to wait for you in the waiting room. Or in the car. Or on Venus.

(EMS not included).

Definition of cold: Killing a Patient to Save His Life –

For the record, I’m all for this, providing it pans out in trials…

PITTSBURGH — Trauma patients arriving at an emergency room here after sustaining a gunshot or knife wound may find themselves enrolled in a startling medical experiment.

Surgeons will drain their blood and replace it with freezing saltwater. Without heartbeat and brain activity, the patients will be clinically dead.

And then the surgeons will try to save their lives.

Researchers at the University of Pittsburgh Medical Center have begun a clinical trial that pushes the boundaries of conventional surgery — and, some say, medical ethics.

By inducing hypothermia and slowing metabolism in dying patients, doctors hope to buy valuable time in which to mend the victims’ wounds.

via Killing a Patient to Save His Life –

You Can’t Yelp Your Doctor – The Daily Beast

Some of the country’s best doctors have the worst patient satisfaction scores. Here’s why.Part of being a doctor is learning to suppress your feelings. You get good at being what people need you to be. But it slowly transforms you into something you couldn’t have foreseen—a sort of Stepford doctor—pleasing everyone with your perfect smile and agreeable demeanor, hoping that your patient satisfaction survey will be favorable, no matter the cost.

Press Ganey is one of the top providers of patient satisfaction surveys, according to the Forbes article, Why Rating Your Doctor Is Bad For Your Health.The government has bet big on these surveys, as a recent article in Forbesnotes. Armed with the idea that “patient is always right,” Washington figured that more customer satisfaction data “will improve quality of care and reduce costs.”

That turns out to have been a bad bet.

via The Mask Your Doctor Hides Behind – The Daily Beast.

Read the whole thing, but it’s what your doctors, especially the hospital based ones, have been saying since day 1.

Healthcare Reform Update: Doc employment won’t lead to lower healthcare spending, research shows | Modern Healthcare

You don’t say.

Market share and prices tend to climb among hospitals that employ doctors but not for hospitals with looser contracts with independent physicians, according to newly published research. The findings, the authors say, suggest that integration itself does not produce the savings that many health system executives and policymakers promise from closer coordination between hospitals and doctors.

Hospital prices, according to the study, increased 2% to 3% each time physician-employing hospitals’ market share increased by one standard-deviation. The results were drawn from an analysis of roughly 2 million hospital bills submitted to private insurers between 2001 and 2007. Overall spending on services at the hospitals that employed physicians grew, while the utilization of services at those hospitals didn’t change.

via Healthcare Reform Update: Doc employment won’t lead to lower healthcare spending, research shows | Modern Healthcare.

All Trials | All Trials Registered. All Results Reported

Many thanks to Steve in the comments on the last post for alerting me to this movement:

It’s time all clinical trial results are reported.

Patients, researchers, pharmacists, doctors and regulators everywhere will benefit from publication of clinical trial results. Wherever you are in the world please sign the petition:

Thousands of clinical trials have not reported their results; some have not even been registered.

Information on what was done and what was found in these trials could be lost forever to doctors and researchers, leading to bad treatment decisions, missed opportunities for good medicine, and trials being repeated.

All trials past and present should be registered, and the full methods and the results reported.

We call on governments, regulators and research bodies to implement measures to achieve this.

via All Trials | All Trials Registered. All Results Reported.

I signed the petition, and hope others will as well.

Realistically, this will require either a mindboggling scandal (even worse than the ones we know about) leading to group self-regulation, or more likely, intrusive and poorly thought out legislation.

I know what I’d bet on.

What the Tamiflu saga tells us about drug trials and big pharma | Business | The Guardian

Hint: Roche stinks, and the Cochrane Collaboration has done all of us a huge favor. Time to stop prescribing Tamiflu.

What the Tamiflu saga tells us about drug trials and big pharmaWe now know the government’s Tamiflu stockpile wouldn’t have done us much good in the event of a flu epidemic. But the secrecy surrounding clinical trials means there’s a lot we don’t know about other medicines we take

via What the Tamiflu saga tells us about drug trials and big pharma | Business | The Guardian.

Navy Matters: A-10 Scrapping Justification Exposed

Please click through and read the whole thing. Something I hadn’t considered.

This is a Navy blog but I just can’t pass on the following Air Force item especially since it indirectly impacts Marine and Navy CAS.

DoD Buzz website quotes Air Force Gen. Mark Welsh as saying that scrapping the A-10 will save $4.2B over five years (1).  This apparently is the Air Force’s justification for letting the A-10 go.  Of course, the real justification is preserving the Air Force’s buy of F-35’s.  Be that as it may …

Let’s check that cost savings number out, shall we?

via Navy Matters: A-10 Scrapping Justification Exposed.

Stolen laptops lead to important HIPAA settlements

In case you wondered why your IT department isn’t reasonable about security, it’s because the penalties aren’t reasonable.

Stolen laptops lead to important HIPAA settlements

Two entities have paid the U.S. Department of Health and Human Services Office for Civil Rights (OCR) $1,975,220 collectively to resolve potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules.  These major enforcement actions underscore the significant risk to the security of patient information posed by unencrypted laptop computers and other mobile devices.

via Stolen laptops lead to important HIPAA settlements.

1.7 Million dollar fine.

Bug can cause deadly failures when anesthesia device is connected to cell phones | Ars Technica

I can think of at least one reason phones are being plugged into USB’s…

Federal safety officials have issued an urgent warning about software defects in an anesthesia delivery system that can cause life-threatening failures at unexpected times, including when a cellphone or other device is plugged into one of its USB ports.The ARKON anesthesia delivery system is used in hospitals to deliver oxygen, anesthetic vapor, and nitrous oxide to patients during surgical procedures. It is manufactured by UK-based Spacelabs Healthcare Ltd., which issued a recall in March. A bug in Version 2.0 of the software running on the device is so serious that it could cause severe injury or death, the US Food and Drug Administration warned last week in what’s known as a Class I recall. In part, the FDA advisory read:

via Bug can cause deadly failures when anesthesia device is connected to cell phones | Ars Technica.

In my practice in the ER, there are two types of patients: those who travel with their phone chargers and plug them in, and those who don’t and whose phones are dying. The former will plug into any power port, the latter are the ones asking if anyone has a charger they can borrow.

So, your loved one is in the ICU on the vent, you’ve been calling and texting for what seems like forever, and you get to sit at the bedside. You’d never think twice about charging your phone off the nearest USB port; it’s never been a problem before, why would it be now?

Why that would shut down a ventilator is terrible planning on the part of the manufacturer, and it’ll get fixed. For you, though, don’t plug your pone into medical gear, as apparently some of it isn’t hardened against real life.


Top 5 Reasons Why ‘The Customer Is Always Right’ Is Wrong | Alexander Kjerulf

Top 5 Reasons Why ‘The Customer Is Always Right’ Is Wrong | Alexander Kjerulf.


Medicare Payments to Providers in 2012 –

Medicare Payments to Providers in 2012
Newly released Medicare billing data show total payments to more than 880,000 medical providers in 2012, totaling $77 billion.
Search the database by provider name, specialty and location to see the types and number of procedures performed and the amounts paid to each provider by Medicare. Related article.

via Medicare Payments to Providers in 2012 –

Use your new powers for Good.

Hilarious Tamiflu side-effect

Okay, it’s not hilarious, it’s funny that it’s included as a side effect of Tamiflu (treatment for influenza):


I’m not a huge fan of Tamiflu (for the neuropsychiatric side effects), but I saw this last night on my pocket brain, and had to look today to see if it’s really listed.

It is, that’s off the Tamiflu full-download of the medication information (Link on the official Tamiflu page).

So you know, when patients are in studies, basically everything that happens while the subject is taking the medication has to be reported to the FDA, which is how all that oddness gets enshrined as less than 1% side effects. I do find it a little amusing that ‘pyrexia’ (fever) is listed as a side effect, since influenza classically has a fever, and the peritonsillar abscess diagnosis quite possibly indicates the patient didn’t have the flu, they had an undiagnosed condition subsequently diagnosed.

Tamiflu is a Genentech product, FYI.

Why the Zero Defect mentality will never work

At least, not in real life:

The idea that “failure is not an option” is a fantasy version of how non-engineers should motivate engineers. That sentiment was invented by a screenwriter, riffing on an after-the-fact observation about Apollo 13; no one said it at the time. If you ever say it, wash your mouth out with soap. If anyone ever says it to you, run. Even NASA’s vaunted moonshot, so often referred to as the best of government innovation, tested with dozens of unmanned missions first, several of which failed outright.

Failure is always an option. Engineers work as hard as they do because they understand the risk of failure. And for anything it might have meant in its screenplay version, here that sentiment means the opposite; the unnamed executives were saying “Addressing the possibility of failure is not an option.”

via » and the Gulf Between Planning and Reality Clay Shirky.

Healthcare has this idiocy. It’s a disconnect between the doers, who will tell you what’s possible, and the managers, who either don’t know or don’t remember.

Leaders, by the way, would know the difference.  Need more of those.

Grading a Physician’s Value — The Misapplication of Performance Measurement — NEJM

NEJM realized the PQRS Emperor has no clothes.

Perhaps the only health policy issue on which Republicans and Democrats agree is the need to move from volume-based to value-based payment for health care providers. Rather than paying for activity, the aspirational goal is to pay for outcomes that take into account quality and costs. In keeping with this notion of paying for value rather than volume, the Affordable Care Act ACA created the “value-based payment modifier,” or “value modifier,” a pay-for-performance approach for physicians who actively participate in Medicare. By 2017, physicians will be rewarded or penalized on the basis of the relative calculated value of the care they provide to Medicare beneficiaries.

Although we agree that value-based payment is appropriate as a concept, the practical reality is that the Centers for Medicare and Medicaid Services CMS, despite heroic efforts, cannot accurately measure any physician’s overall value, now or in the foreseeable future. Instead of helping to establish a central role for performance measurement in holding providers more accountable for the care they provide and in informing quality- and safety-improvement projects, this policy overreach could undermine the quest for higher-value health care. Yet the medical profession has been remarkably quiet as this flawed approach proceeds.

via Grading a Physician’s Value — The Misapplication of Performance Measurement — NEJM.

How many tens of thousands of hours are spent jumping through hoops like these that turn out to be more meaningless (or worse) ‘government work’?