Wednesday, February 27, 2008


(medical students, residents an PAs) While rounding this week I tried to determine how much time was spent writing in charts and doing all the documentation and charting that is required. It worked out to be about 5 minutes for a routine uncomplicated hospital follow up, 7-10 for a moderately complicated case and about 15minutes for a new consult. This was of course without the docuslaves, those who are there to learn medicine but instead are relegated to writing all the mumbojumbo in the charts that means nothing, that is only read by attorneys, insurance companies an JACHO. I woul so love if all that time was spent on the patients instead. I feel sorry for the rns, for them it is the opposite, the students do the real care while they are force to write all the stuff. It is the old story, if it isn't written in the chart it wasn't checked.

The real sad part is that the chart is what we are supposed to use to communicate with each other as we take care of the patient. There is now so much junk in it that it is hard to tell what is actually going on. Isn't better documentation great!

Saturday, February 23, 2008


I was just told by one of my best friends who is an attorney (hard to beleive isn't it!) what the main difference is between the professions of medicine and law is. In medicine we are trained to be accountable for everything. In fact we hold ourselves responsible and are held responsible for things that are beyond our control. Attorneys on the other hand strive to be accountable for nothing and hold everyone else accountable. He explained it this way, "In what I do, I advise people what I think but then make sure the real decision and accountability is theirs. In fact, in big things were we go to court we pass the buck farther and make the jury of the judge accountable. We also make sure that it is very hard to be sued for malpractice .When things don't go well it was the clients choice. We even limit our accountability further by forcing the client sign arbitration agreements. In medicine you are the responsible party. If anything goes wrong it is your fault. If the patient makes a bad choice, you are responsible because they can come back and claim that you did not give them enough information. If the cancer evades the surgery and chemo/rads it is because of you not the disease."

He then said, "If I lose a case it is because it was a bad case or the decision of the client, judge or jury. If you lose a case, the perception is that there was something else that you should have done, or that you did wrong."

"Another way to look at it is this. If you ask an attorney to watch you house while you are away, he will have you sign a detailed document that spells out exactly what is meant by watching the house in such a way that if something happens he is not held resposibile. The doctor wont ask what is meant, assume that he is responsible for everything, move the house to where everything can be watched by a team that is also held accountable, and ensure that it has every monitoring device possible to the limits that can be paid for."

The moral of the advice, in Law, it is always someone else's fault and they should pay. Moreover, the attorney is just a consultant and tries everything he can to make sure he is not accountable. In medicine, the physician is accountable for everything, society and attorneys strive to make sure this is the case. Who do you want to watch your house.


Following the elections there has been so much talk about "Universal Healthcare" but I wonder just what does "Universal" mean? I have a universal cresent wrench but it doesn't fit big bolts. My universal remote for the entertainment center is always on the fritz and doesn't work for off brand TVS. When Hillary and Obama talk about universal care, just what exactly are they saying they will pay for? I love when they throw out numbers about how much it will cost so they must have some ideas of what they will pay for. Will it be like Europe where you are over 65 so no dialysis for you,, artificial knee, no way? Or will it be pay for everything to get the vote? You can make it save a lot if you don't cover much. (Canada)

I know that it is politics so I should not expect much, but even with researching their plans I have yet to find out what they will pay for. There are general statements but nothing that actually spells it out. While they are debating the so far meaningless word "Universal", we will continue to take care of patients from France, Germany, Spain, Italy, Canada, Sweeden and the UK were "Universal Care" has been defined. (I know that there are patients from other countries with national healthcare but these are the countries that people have put pushpins on our "where are you from?" map.

Midlevel maddness!

With the explosion in the number of minute clinics as well as NP and PAs in many offices we have seen a huge jump in the number of consults that we see. I guess this is a good thing in the business sense for us but I am concerned at what it means for healthcare in general. We are used to seeing routine things as part of the "CYA" crisis that medicine is in, but this is different. I can't tell you how many "pulsatile neck masses" we see are the carotid artery and thyroid masses are the cricoid cartilage. The midline abdominal mass on the thin gentleman was the xiphoid! I guess if bothers me as the patients went to someone who charged them and then sent them to a specialist where there was another charge. Whats worries me even more is what are they treating that isn't what they think? How many back pains are disecting aortas? Belly pains are colon ca? Headaches are GBMs?

I know that there are great midlevels and I am rapidly getting to know who is who but at the same time I really can tell that a consult from one is not the same as one from a MD or DO. I was talking with a friend of mine who is also my PCM. He has several pas in his practice and they are great and run cases past him. They are fantastic! I worry when there is no one reviewing what is going on. One thing that I learned in medical school and residency is that the art of medicine is sperating the mundane from the serious.

Friday, February 22, 2008

Foley to Buck's traction

Foley's are very common in the hospital and a part of routine care for many patients. They can cause infections as can any other invasive device even with the best care . Medicare has announced that it will not pay for what it considers preventable complications such as utis from foleys. Here is the problem. The patient who wants to smoke and of course can not do so in the hospital went out for a couple of puffs. On his way though the revolving doors he accidentally droped the foley bag and the drainage tube went under the door skirt. It is amazing how much momentun those doors have. Unfortunately, he was outside the door when he realized what happened and it was too late. As you can imagine, the foley came out, balloon still inflated. After the bleeding subsided, he of course had a UTI. Do you think that Mediare will balk at the charge.

In medial school I was told of a patient at a VA who stepped out of an elevator and left his foley bag in the elevator only to be pulled to the elevator doors as he watched the foley tube go higher and higher until "ouch!" but I figured that the story was an urban myth. Now I am not so sure.

Condition upgraded!

I was on my way home when I heard on the radio that one of my patient's condition was upgraded from critical to stable at 12:30pm. I though this was strange, who upgraded his condition? I know I didn't. In fact, what exactly does condition mean? We sometimes write condition in the initial admission orders but I have never seen an order on any chart that says "upgrade condition to stable". Is there someone in the hospital that is in charge of this, and if so why is in not a HIPPA vioation? There is probably some JACHO form buried in the chart about this that I don't know about and will subsequently get a nasty gram about. In the mean time I think I will use a condition scale like, sick, sicker, and really sick. I will make sure that it is written out and not an abbreviation so it is not a JACHO violation.

I think a better way to judge condition is the number of catherters inserted into the body. IV, foley, ng, chest tube, central line, swan, ballon pump, surgical drains, g tube, icp bolt, art line. This way the reporter could say "MR. Patient is now a 7 instead of an 8".


Just doing my charts. 37 is the number of pages in the patient's chart who came in to have some propofol for a minor hardware removal. the records people reminded me that it is not the number of pages but the fact that each page had to be filled out by someone. This takes time and then the records people go through the chart to make sure that the people filled out everything correctly. This got me going to see how much was clinically revelent. Well, there is the history and the consent. Everything else was there becuase of some guideline or JACHO thing. I counted that 11 different people had written in the chart.

I asked medial records if the new EMR will decrease this. They said, it may decrease the amount of paperwork but it will still be the same number of people filling stuff out and instead of being able to do it in the or and bedside, they will have to find a computer and log on and hope it doesn't crash.

I like the people watching my patients to be watching my patients not trying to make sure paperwork is well cared for. Then again, on rounds it takes me 4 times as long to fill out the chart as it does to actually see and care for the patients.

Thursday, February 21, 2008


Typical night in the ER, sewing up a forhead laceration in a gentleman with a blood alcohol level of 0.36. He is a pro and is actually quite licid. He mentions, "Dude! The hospital must sure pay you guys a lot!" I wanted so much to correct him but he had a fit of ketone smelling vomit that I was afraid would catch fire.

I asked around as was supprised at how many people think that doctors are paid by the hospital. We have been trying to get paid for taking call but for the most part taking call is part of the deal to use the hospital to take care of your patients. The only way we get paid when we come in on call is if the patients pay us. In the case of this gentleman, all I get is a chance to wreck the car coming in at 3am, to be tired all the next day and lastly to be sued when he doesn't like his scar. This is part of the job however.

When the ER is filled with patients who don't pay, it becomes harder and harder for physicains to cover call. This is not care rendered for free but rather it costs the physicians as these patients are still followed up, seen in the office and the time and overhead is paid for by the physician. As a result, we are seeing docs drop out of call at an alarming rate. When you add that emergency care is more likely to get you sued, they leave the call system asap. One solution is to re-emburse physicians for taking call.

In the past, hospitals could employ physicians but this has been turned on its head by the medical regulations from Pete Starks laws. Hospitals that employ physicians are in danger of violation the law and this inturn means that the physicians must serve as a sort of sub-contractors within the hospital. This is true even for radiology, pathology and anesthesia. In each case, patients are billed by the doctor groups for the actual professional services of the physicians seperately from the hospital. A way around the Stark laws is that the hospital can pay a stipend to take call to defray the cost that is mandated by the hospitals. In some places this is working, but I am sure Pete Stark is well on his way to outlawing this as well.

Wednesday, February 20, 2008

Critical thinking

I was just looking at another blog that was taliking about a jury of your peers and I wondered how that system would work in medicine. That is if the peers were the same ones that were used in a trial. I think that it would go something like this.

ER, this is Metro ACLS rig 5 minutes inbound with 54y/o female, unconscious with pulse 140, bp 60 palp attempting to intubate, found down no history.

Quick, get our jury pool. Exclude anyone in medicine or a technical field. Get rid of anyone with education higher than 5th grade and be sure that it is ethnically diverse, wait, what is the race of the patient? Get rid of the guy with the short hair, just because. Oh, be sure that there are more mothers as they will be more sympathetic.

Patient rolls in the ER, EMTs can't intubate, sats 60%. Get the opposing medical counsel. Line up the expert witnessess. Schedule the trial date to determine what to do. We have to get the jury to tell us what to do. This is important and we got a jury of our peers!

Oh, never mind, the patient didn't make it.

Personally, when I hit the ER, I wan't a group of ER docs that take care of me. Educated docs who have experience and know all they an about what is going on.

Our tort system needs work. In the meantime, important decisions are being made by "peers" in whom the educated, experienced are excluded and opposing attorneys choose those jorors that the feel will be the most easily influenced.

Lights and Sirens

Remember when people pulled off the road or to the side to let an ambulance pass? It sure doesn't appear to be like this anymore! We had two rigs stuck in traffic two blocks from the trauma center. In both cases people could move to get out of the way but didn't. One of the drivers actually got out and asked the driver of the car infront of him to pull aside. He had to wait for the guy to put down his cell phone!

I asked the driver how he handles it, his response was that it happens all the time. He even told me that on the interstate, drivers tailgate him thinking that he will help them get through traffic.

I know that it would be bad to wish that someday the drivers who don't get out of the way of the ambulance will have the chance be the patients in the back that desperately need to get to the ER.

Purple heart

Boy, you talk about taking a hit for the team. The ERs are full of patients coming in with the flu and one by one the medial staff is dropping. The first was our receptionists, they are at ground zero, meeting each patient and getting hacked on. Fever of 103F with muscle aches that make you wish to be intubated they went on the injured reserve. The techs and nurses were next. Even with the best of universal precauations, they went down. ER docs, PAs and NPs weren't immune despite the flu shots and gallons of Tamiflu.

Running on skeleton staff the ER is doing its best. The hospital is filled with those with the worst of the flu. Some intubated on vents, some barely hanging on. The respiratory therapists fighting the flu themselves struggle to keep patients oxygenating.

Everybody is getting sick but that is part of the job.