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I am often asked how much we get paid for an office visit. So I really tried to find out the answers. Here they are:

For an established patient following up, relatively straight forward Medicaid pays: $24.74, Medicare pays $35.36.
New patient expanded visit is $34.42 from Medicaid or $60.08 from Medicare.
Telephone consultations or calls $0.00
Initial hospitalization (admit to hospital) Medicaid $55.71, Mediare $117
Critical care, first hour $95.19 then $46.42 for each additional 30 minutes
Intubation for respiratory failure $90.13


I think that it is interesting that attorneys get $200/hour or more while we get $95.19/hour for critical care.

Plastic wrap annoyance

Call is finally over, now to do all the things that I did not have time to do like take out the trash. One of the bags is overflowing so I did the foot smash to compact it and looked in. It was kind of eye opening. Almost all the garbage was some kind of plastic wrap or paper plastic combination! There was blister wrap from batteries, burrito wrapers, the plastic that comes over everything. I looked in the pantry, everything seems to be covered in plastic.

I started to wonder, where does all this plastic come from, of course it is from oil. What do we do with all this stuff, why throw it away of course. So here is the idea, instead of getting everything wrapped in plastic could I just get it and take the oil in the form of gasoline? At least that way I am getting some use of it instead of just trying to find a way to rip it off of what I really want and then throwing it away?

Ya get what you pay for (sort of)

One of the things that I love about my job is I get to take care of anybody regardless of their ability to pay. I can't help but wonder though what that effect is on society as a whole. For example, right now about 20% of the patients in the trauma unit are illeagals. Their care is being paid for by funds from citizens with insurance and from the hospital with a portion of federal funds. So, in a sense we are all paying for their care. I know that in the large scheme of things that this money has to come from somewhere and that we all are in some way paying the bill. It is easier to just do the medicine and not worry about the bigger picture!

Up one, down two

July is almost over, so far the new interns are doing well. We have had a few moments but overall they are learning. Going on rounds looks like Mama duck with all her little ducks winding from one room to another. You can tell how far along someone is in residency by how little is in their pockets. The interns all have lab coats stuffed to the brims with Wash manuals and poket pharmapedias. The senior residents are in scrubs with a sweatshirt. All have coffee or diet colas.

As we round we try to teach the residents the important things, like you take the stairs to go up one flight or down two. Keep your wallet in the inside pocket of your scrubs. Wounds heal side to side, not end to end. Dyspareunia is better than no pareunia. You can always find hemeacult cards but never the reagent. Surgical caps hide bad hair days. There are always bullion cubes and crackers to eat. Never try to drink Jevity. Ward clerks save you butt, charge nurses are there to make you miserable. Crying and complaining mean that the patient is oxygenating. Patients bleed whole blood not packed red cells. Patients dont die of pain, they die of too much pain medication. If you decide to send the stool specimen to the lab through the tube system, make sure the lid is screwed on really, really good! Patients with no arms or legs can still pull out their feeding tubes.

There are many more, but its a 5 to 6 year residency.

Bug light

I was on my way to the OR late at night for an urgent case. On my way, I have to walk up a long hall. There is the red line before the surgical area that represents where surgical scrubs are needed. The OR suites are positive pressure so that there is always a breeze coming down the hall when the doors are open. I looked up and there was a moth, flying upstream as hard as it could to get into the OR area. He was focused on the bug lights that are just beyond the door. Try as hard as he could, he just could get there. The doors would shut and he would fly around and bump into the windows of the door. The door would then open and there would be a whoosh and he would beat his wings as hard as he could to try to get in. Finally, with an incredible effort he makes it! Only to fly right into the bug light and get zapped in a flash of bright light and smoke.

You know, when I am on call, I feel like that moth!

GOMER HOMER

I don't know how they do it, but they are amazing!!! These are the case managers who somehow find placement for patients. We are losing nursing homes like crazy as they can't afford to stay open on what little re-embursement comes their way, not to mention skilled facilities or even rehab centers. You can get the patient through the ruptured spleen and the liver lac but the closed head is going to take a while to clear. The case managers step in and try to do their magic. They work in these little closed rooms trying to find somewhere that will accept the patient who is uninsured has both a trache and a g tube.

We had two facilities here in town but both are being sued and already are in the process of shutting their doors. Both of the suits involve patients having decubes and thus the family who doesn't and didn't care before has sued. It doesn't matter that both patients are in air beds and moved constantly, or that their hypotension from their injuries cause the sores. All that matters is the money.

I don't know who is going to accept these patients in the future.

PDR Quagmire!

It seems that almost every day in clinic I have a patient who stops their medications when they look at the PDR or the volumes of legalese side effects that are listed by the pharmacy paperwork. The most recent was a patient who stopped her diabetes medication because she saw a statement that it might increase her risk of heart attack. Apparently she did not realize that it was her diabetes that increased her risk of heart attack and her sugar went over 400 and she came in dehydrated and confused and tried to die in the ER.

I try to explain that these side effects lists are written becuase of lawyers. What happens is that when a drug is tested any possible thing that the test patients experience is listed. This is why you see that every drug seems to cause ringing of the ears, colds, bronchitis, abdominal pain, etc. You are giving the drug to thousands of patients and so if they get a cold, it is on the list. If there ears ring anyway, it goes on the list. The PDR and the other lawyer sources dont say that the incidence of these things is the same as the placebo group because that doesn't help you in a lawsuit!

Oh, my other one this week was a patient with afib on coumadin who did not want to go in the hospital and be on a heparin drip before her valve surgery. She had heard on TV that heparin can cause headaches and other problems. Oh, it was an attorney advertisement. When I explained that she could not be on coumadin for surgery because she would bleed to death, and that if we just stopped heparin she would throw a clot and die, suddenly she though heparin was a good idea.

11!!!!

(on a scale from 1-10). This adding pain as a vital sign has really got me worried. It seems that every patient I see in the ER describes their pain as 11 on the 1-10 scale. It doesn't seem to matter what is wrong with them. I go and look at their medications and of course they are on lortab and oxycontin for chronic pain so their receptors are totally screwed up and the little bump that they sustained from falling has interrupted their narcotic induced altered state of existance. One friend of mine put it to me clearly. He said, "look, they think normal is how they feel when they are on their narcs so just being normal causes them to think they are in pain!" I don't know when people began to just write prescriptions for chronic lortab or percocet but I sure would like them to have to see what has happened to their patients. Personally, I have an occaisional sore back that vioxx and bextra helped and I wonder how many of these people did well on these meds before they went off the market. Now, they can't get relief and some poor "good intentioned sod" started them on narcotics making them total addicts.

Of course there are the chronic drug seekers. You can spot them pretty easily because their pain is always a 11 and secondly they cant describe the pain. You ask them is it a stabbing or aching pain, burning or throbbing and all they will say is that it hurts. You ask them where it hurts and they will be vague about it as well, not to mention they can't precisely tell you when it started. The guy with the rib fracture will tell you the millisecond it happened, that it throbs when he takes a deep breath and will point right to it. (His pain was a 4) Drug seekers are always allergic to NSAIDS, have anaphalaxis from toradol, hives from Ultram and the only thing that seems to help there pain soulds like laudid. People in real pain just look at you and say, "I don't care what it is, just make it not hurt so much!".

I got a fax from a group of doctors that it trying to see if a vioxx or bextra can come back to the market. It was a petition, I signed it.

I can't wait for the next JACHO vital signs like anxiety, mood, appetitie, sexual eagerness, and favorite color. It is a good thing that I am not in charge because I would add vital signs like intellegence, probability of following medical advise and body odor listed.

Otis Nirvana

Elevators are one of the greatest benefits of a large teaching hospital. While on the floor or in the OR the beeper goes off constantly. It never goes off for something good, it only goes off when there is something else for you to do. Each time it goes off, you try to find a phone and although it was important enough to page you for, the person who paged never answers the phone. So while you wait for them to get that person, your beeper goes off again. (cell phones are not to be used in hospitals because of problems with telemetry). After what seems like the 10th page, you get in the elevator. It is paradise! You cant answer a page and if you are lucky it will stop at every floor on the way to where you were going. Often, the pager doesn't even work in the elevators. A good 10 to 12 floors might mean 10 minutes of respite. I hate to admit that even when I am alone in the elevator, I push extra floor buttons.

D-DAY

05:30 am the first wave of new surgical interns hit the beaches, some were immediately hit by scut fire while other rose only to get taken down by a barrage of pimping from senior residents. Those that made it to the trenches hunker down waiting for the attendings while they hope that they don't commit any friendly fire accidents while running the gauntlet from the surgical wards to the OR.

July 1st is the day that all the new interns start and the residents move up in rank. It is generally a good day to not be sick in the hospital. Besides residents, new nursing students, case managers an RNs are also starting so that everyone is learning the ropes. The older folks are extra vigillant as they try to catch errors and keep the teaching hospital running. Choas has its own intertia.

The new interns look so young that it hard to believe that we were that age or even that we once had ironed white coats. Their coats are full of books and stethescopes as opposed to ours that are filled with muliple little pieces of paper and a few partially eaten "snickers". The new interns have the look of terror and excitement in their eyes. Excitement wears off though, terror grows. It won't be long before they are all addicted to coffee and will have learned to sleep standing up and be tempted to drink some have used enteral feeding.

So begins the trial by fire. Some interns will do great, other will fail. It is time to sort them out.