A day of Emergency Medicine?

Today was the first day back to work after a four day holiday. The patient acuity was high, which was a nice change:

  • The Septic Senior, with a-fib at 200, a systolic of 70, on digoxin and coumadin,
  • the Trauma Transfer, with the as-billed bleeding liver lac and free abdominal air, but also including the the undisclosed spleen lac,
  • the Arrest in the Ambulance Bay, who died despite all our efforts,
  • the Killer Back Pain, with the Type B aortic dissection,
  • the Altered Mental Status, with some dehydration and a seizure disorder on the side…

And those were in the first two hours. I really believe that some people ‘hang in there’ through the holidays, and then pay the piper for the privilege.

And, those who are sent to remind us to be humble, and maybe a little miserable.  The patient who, when presented with their diagnosis (really, irrefutable given the history and testing), says

  • “I don’t agree”.
  • me: Yes, it is. That’s what all the tests are for.
  • pt: “No. I have an Uncle who was a doctor, and I have my own Merck Manual, and I don’t think that’s right.”
  • me: Ummmm, okay …

All in all, a good day to be an Emergency Physician.

More busybodies who should butt-out: Anti-porn Groups Demand Ban on Skin Mags

Anti-porn Groups Demand Ban on Skin Mags
Anti-porn Groups Demand Ban on Skin Mags
UPI | November 06, 2007
WASHINGTON — Dozens of anti-pornography groups asked the U.S. Congress to force the Pentagon to keep sexually related material from being sold in military stores.Pornographic material was banned from being sold in military establishments nearly 10 years ago, but Christian group American Family Association claimed that adult fare, including Penthouse and Playboy material, is still being sold in the stores, USA Today reported Monday.

Umm, we’re not talking about sales to minors here, we’re talking about adults (male and female) who are willing to put on the uniform and put up with the inevitable deprivations. Should they decide to spend their dollars on smut it isn’t anyones’ business but theirs. And, Congress should be ashamed they pandered and caved on this trivial issue.

I’m a personal little “l” libertarian on issues like this, and it’s nobody’s business what legal product is sold on base to adults. Cigarettes are still sold there, by the way, but this faux-moralism is a fun club for the holier-than-thou to wield.

Oh, and they should be able to drink at 18, too. That’s not part of this, but I just wanted to get it out there.

Blogger stinks, captchas are bad; incidentally, a response to ERNursey

ERNursey,

I tried to leave this as a comment, but you have that utterly horrible blogger captcha, and I tried to do it, but it stinks to high heaven.

Here’s my response to her post:

How?

The mentally ill don’t vote. (Insert your funny joke about the party you don’t vote for here).

Their families are a mixture of positions, and I understand, in theory. Psychotropic meds (Thorazine, Haloperidol, etc) were going to revolutionize mental health care (1965 and later); screaming psychotics then became somewhat medicated psychotics. Not droolingly crazy = unfair holding against their will! !Close the horrible institutions! They just hold people who’ll be fine’ (if they take their meds; when they leave very close supervision in a structured environment, they usually don’t). Then they’re on the street, literally.

One of Americas’ few real shames is the number of homeless who need to be institutionalized due to mental illness, but aren’t. Land of the Free, home of the brave, but no home for the decompensated schizophrenic.

Mental health is a life-long problem, and the patient pool we’re talking about here aren’t unhappy about their latest relationship, they’re literally coo-coo for cocoa-puffs, except that makes them sound more cartoonishly pleasant than they really are. They’re miserable, through no fault of their own, and there’s nowhere to go.

There’s plenty of blame to go around here, on both political parties and over a couple of generations. Money is the root of evil here; long term mental health care is horribly expensive just because it’s lifelong. Many states are closing their long-term MH Hospitals due to cost. It’s hard to get re-elected on the tax bill for the mentally ill; inexplicably, toll roads get people re-elected. Go figure.

I want legislation that puts a homeless schizophrenic on the corner next to every legislators’ home (there’s plenty to go around), and then maybe, just maybe, something will happen. Until the mental health advocates and the courts get involved, then they’re all back on the street and in the ED.

GruntDoc

Blogger site bloggers: the blogger captchas are bad, they’re stifling, and you need to get rid of them.

Austin to deliberately dump mental health patients on ED’s: your waits to increase

Aah, Texas Mental Health: “Just Go to the ER”.

Some mental health patients to be diverted to ERs

State tells local mental health agency to stop overusing Austin State Hospital.

statesman.comBy Andrea Ball
AMERICAN-STATESMAN STAFF
Thursday, November 01, 2007

More people with mental illnesses could soon be sent to local emergency rooms instead of Austin State Hospital, and hospital officials say that could clog waiting rooms and cause longer waits for medical care throughout the Austin area.

On Nov. 8, the Austin Travis County Mental Health Mental Retardation Center will start reducing the number of people it sends to the state hospital by 43 percent — an estimated 600 to 900 people each year. Those people will be taken to emergency rooms, including ones at Brackenridge Hospital, Dell Children’s Medical Center of Central Texas, Heart Hospital of Austin and St. David’s Medical Center, said Jim Van Norman, MHMR’s medical director.

The only solution, Evans said, is to stabilize people in emergency rooms until a psychiatric hospital bed can be found.

“No one hates this more than we do,” Evans said.

Oh, I’d bet you’re wrong there, Mr. Evans.  The patients will hate it, their families will hate it,  the entire staff in the ED now caring for a patient they’re not equipped to deal with and cannot disposition will hate it more, and longer, than you.  (I keep deleting a really snarky line here: feel free to make your own).

The move has local emergency room doctors expressing concern.

“This is truly a disaster waiting to happen,” said Pat Crocker, chief of Dell Children’s emergency department. “It’s going to affect medical care for every citizen in Travis County.”

Dr. Chris Ziebell, medical director for the emergency department at Brackenridge Hospital, said the hospital isn’t equipped to be a mental health crisis center. There is no secure place to keep patients who may be violent or disruptive, and medical staffers are not trained to provide the specialized mental health care, he said.

“I can knock them unconscious, but that isn’t going to make the mental illness go away,” Ziebell said.

Meanwhile, those patients can tie up emergency room beds for several days while waiting to be admitted to a psychiatric hospital.

It’s a solution from the MHMR standpoint: patient not in their waiting room = problem solved!  Except all you’ve done is shifted the responsibility from those whose it is, to those who aren’t able to turn any patient away.  Unconscionable.

[Really good background on the roots of the problem and Austin's reluctance to pay for what they use in the Texas Mental Health hospital system.]

Whatever the long-term solution, Ziebell hopes it doesn’t involve leaving mental health care to emergency room staff.

“Sending someone to the ER when they’re having a mental health crisis is like going to the proctologist when you have a heart problem,” he said. “This is not the right place for them to get treated.”

(All emphasis mine).  This is not a solution to the problem, it’s abdicating a responsibility.  And it’s shameful. 

Best of luck, Austin ED’s.

KevinMD on CBSNews.com; oh, and a bad example of defensive medicine

Defensive medicine is indeed a problem. This isn’t the example that tells that story. Oh, and Kevin looks pretty good on TV.

CBSNews.com
Defensive Medicine: Cautious Or Costly RICHMOND, Va., Oct. 22, 2007(CBS)

It started as a simple stomach ache, but Alexandra Varipapa, a sophomore at the University of Richmond, decided to go to the emergency room.

There, doctors ordered a full CT scan, a radiation imaging test, which found a harmless ovarian cyst. She never questioned the CT scan, CBS News correspondent Wyatt Andrews reports.

Wow, she walked in and just got a CT scan! Oh, wait, she also got a history and a physical exam, but you wouldn’t know that from the slant of the article.

But her father did – when he got the $8,500 bill, $6,500 of which was that CT scan.

“I was pretty flabbergasted,” said Robert Varipapa, himself a physician.

Varipapa says his daughter’s pain could have been diagnosed far more easily and cheaply with a $1,400 ultrasound.

“A history, a pelvic examination and probably an ultrasound,” he said. And he would have started with the ultrasound.

Aah, a doctor relative with a retrospectoscope. Stepwise testing works just fine in the clinic, but in the ED we need to do a lotta things in a hurry:

  • rule out the horrible thing
  • get a diagnosis, or exclude the killer diagnosis
  • get the patient out of the ED to make room for the next patient

But the hospital defends the CT scan, saying an ultrasound might have missed something more serious.

“It would not have ruled out appendicitis obviously, it would not have ruled, necessarily, out a kidney stone,” said Dr. Bob Powell, ER medical director of Bon Secours St. Mary’s Hospital.

Varipapa agrees, but asks why not start simple – and do the CT scan only if necessary?

“Well it’s my opinion this is defensive medicine,” Varipapa said.

Well, you may be right that it’s defensive medicine, but that doesn’t make it incorrect, or bad medicine. A better question would be the 6K charge for a CT scan, but bashing the ED is a lot easier. Frankly, this is not a terrific example of defensive medicine, but is a good example of a) the different thought processes between clinic and EM doctors, and b) a cautionary tale of current ED costs.

Kevin looked very reasonable and professional (and wasn’t wearing his pajamas)! Here’s his CBS video. I recommend it, mostly to see Kevin before he moves to Hollywood.

Update: TBTAM weighs in, on the side fo the ED!

“Blogger”, not pedophile

How’s CNN feel about bloggers?

Blogger%20arrested%20near%20UCLA

I guess ‘pedophile arrested’ is dog-bites-man, but this seems a little much. (Yes, he had a blog. It was disgusting (reportedly), and was shut down).

Methinks bloggers have irritated CNN a bit.

The Future of Universal Healthcare: A Warning

I am skeptical of socialized medicine / universal healthcare / give the unsolvable problem to the Government and hope for the best plans. Why? Our government.

The New York Times (h/t anonymous reader #9) reports the following:

August 12, 2007

Select Hospitals Reap a Windfall Under Child Bill

WASHINGTON, Aug. 11 — Despite promises by Congress to end the secrecy of earmarks and other pet projects, the House of Representatives has quietly funneled hundreds of millions of dollars to specific hospitals and health care providers under a bill passed this month to help low-income children.

Instead of naming the hospitals, the bill describes them in cryptic terms, so that identifying a beneficiary is like solving a riddle. Most of the provisions were added to the bill at the request of Democratic lawmakers.

One hospital, Bay Area Medical Center, sits on Green Bay, straddling the border between Wisconsin and the Upper Peninsula of Michigan, more than 200 miles north of Chicago. The bill would increase Medicare payments to the hospital by instructing federal officials to assume that it was in Chicago, where Medicare rates are set to cover substantially higher wages for hospital workers.

The article goes on to name names, on both sides of the isle, who’ve used the power of legislation to reward / give money to one hospital over another for entirely non-transparent reasons.

This is before Congress completely controls the medical system. Think Governmental regulations are onerous now? Just wait until every medical complaint is, in effect, a Federal case. “The Congressman’s office called and wants answers” is going to get a lot more attention, and response, than the current complaints. (I’ve seen a tiny amount of this, when in the military: the Congrint (a congressional inquiry) would absolutely stop the Battalion senior staff who spent the next several hours jumping through hoops to answer whatever questions were put to them (usually regarding a complaint from a Marine or Sailor about some percieved maltreatment)).

I’m not so naive as to believe this sort of political foolishness is new, but for now, consider you’re a competing hospital of the ones that just got congressionally mandated favorite-son treatment. Being a hospital administrator is now even harder than it was, now you’ll be expected to curry favor with the Political Class, else your hospital is at a disadvantage, at least. You can be the most efficient system in town, but you’ll lose to the one who gets the pork.

Given the historic levels of corruption in Congress in the last several sessions, I’m now even more leery of turning the whole system over to them. They’ve earned their popularity (24%).

Where’s Flea when you need him: New Statement Issued for Emergency Care by Pediatric Primary Care Providers

From Medscape:

July 5, 2007 — The American Academy of Pediatrics issued a policy statement identifying the best approaches for pediatric primary care providers to provide emergency care for pediatric patients. The statement, which notes that pediatricians and other pediatric primary care providers are critically important members of the pediatric emergency care team, is published in the July issue of Pediatrics.

Okay, no problems there.

“High-quality pediatric emergency care can be provided only through the collaborative efforts of many health care professionals and child advocates working together throughout a continuum of care that extends from prevention and the medical home to prehospital care, to emergency department stabilization, to critical care and rehabilitation, and finally to a return to care in the medical home,” write chairperson Steven Krug, MD, and colleagues from the Committee on Pediatric Emergency Medicine. …

Wow, cliche-inclusiveness run amok.  I’d just point out that ‘prevention’ isn’t part of Emergency Care, and that the concept of the ‘medical home’ gives me the willies.  The rest of the article is actually pretty good.

Aaah, Flea.  It’s times like this I miss your ED hatin’ ways.

Professional Scolds of Medicine

There are those in medicine who hold themselves out as so terrifically thoughtful and sensitive and a) since they’re so terrifically sensitive and thoughtful everyone should do what they believe, and b) if you don’t, you’re wrong, and unprofessional to boot. They’ll look down on you, and want you to look down on yourself, too. They’re fun to annoy by not playing their game.

I have thought about this before, but Ad Libitum’s latest made me remember why I avoided a few of my peers in med school, and why I like the refreshing groups of realists I work with in Emergency Medicine.

The point of the post is that, essentially, docs cannot ethically blog about their patients, and I take exception to that. Per Ad Libitum

The key underlying principle about physicians writing or blogging about their patients is that, as pointed about by Charon (2), patients own their stories. In fact, Charon recommends that physician-writers must have patients read and approve any narrative about them for publication.

I don’t know a thing about Dr. Charon, but I don’t buy this underlying assumption, so the rest is built on nothing. To accept this idea makes the Physician some sort of detached bystander, which isn’t how medicine works as I practice it: both I and the patient are part of their story; yes, it begins as the patient’s story, but once they communicate it to me, as their doctor, it’s OUR story. (Personal stories are like secrets: the only way to have one is to never tell it to anyone else).

IMHO there is nothing unethical in blogging about patient interactions provided they’re suitably anonymized, and not illegal (which is different) providing you follow the HIPAA guidelines. Although I won’t hold myself out to be a paragon of blogging perfection, when I blog about patients they’re so anonymized that frankly I’m more at risk of a non-patient of mine thinking I’m writing about them than my actual patient (or patients) that spurred the post. As a practical aside, it’s unlikely any of my patients will ever find this blog, let alone scour it to find a case that might be them (hint: it’s not you).

More Ad Libitum:

…It can alter the blogger-physician’s view of patients – each patient encountered can now be seen as a subject about which the physician can write or blog, and the physician may change his or her interaction with the patient in order to extract more writing/blogging material.

Anyone who does this is an idiot, and I wonder about people who worry about such things (more Scolds). Medicine is hard enough without trying to view every interaction through some ‘is this bloggable filter’, and I bring this up here to squash it like a bug. I and every other medical blogger don’t write about 99% of our interactions, and it’s because they’re either not noteworthy, or too noteworthy (not able to anonymize) or we just forget. Frankly, most of what we do isn’t that interesting, or notable, like our patients.

I don’t think Ad Libitum’ a scold, by the way, but I do think the premise of his post is off: it’s not unethical to blog about patients, providing common-sense precautions (and good judgment) are used.

Welcome to Intern Year : PANDA BEAR, MD

Welcome to Intern Year : PANDA BEAR, MD

(Gentle readers, I present the following which is mostly written in Marine-speak. You have nothing to fear and yet, if you have a weak constituion or are easily upset I implore you to skip this article, perhaps using the time saved to peruse the latest Peanuts comic strip in the newspaper or anything else that is similarly non-threatening.-PB)

Heh.  Nice.

New York Times on HIPAA

Keeping Patients’ Details Private, Even From Kin – New York Times

Seriously, what did they expect? A hundreds+ page law by lawyers for lawyers, about medicine, with the threat of major fines, loss of billing abilities, and they wonder why healthcare workers have become close-mouthed? (The executive summary runs 11 18 pages, if that tells you anything).

Read this article, and wonder: their fix for over-caution?

Senator Edward M. Kennedy, Democrat of Massachusetts, a sponsor of the original insurance portability law, was dismayed by the “bizarre hodgepodge” of regulations layered onto it, several staff members said, and by the department’s failure to provide “adequate guidance on what is and is not barred by the law.” To that end, Mr. Kennedy, along with Senator Patrick M. Leahy, Democrat of Vermont, plans to introduce legislation creating an office within the Department of Health and Human Services dedicated to interpreting and enforcing medical privacy.

I’m reassured already, and feel this extra layer of scrutiny is just what we need in the trenches to feel better and just trust that our on the spot judgment won’t lead to protracted guilty-until-proven-innocent government investigation.

(An amusing aside: when I had a wireless internet connection the company put the router in a box and padlocked it. This was inside my house. I asked why, and was told, ‘we do a lot of work with the Healthcare industry, and you’re a doc, so we want to make sure there’s no HIPAA violations. I kid you not. HIPAA paranoia isn’t just healthcare workers.)

If they were serious, they’d re-write this abomination to cover actual, major and intentional lapses in privacy, keep the Healthcare Portability provisions that started this, and junk the rest. It hasn’t helped.

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.

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?).

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

By JAYA NARAIN –

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!

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.