Tuesday, September 30, 2008

Professional Posers

One of the first things that I learned in my career, is that if you want to know who is the best surgeon for yourself, family and your patients, find out who has operated on the most people in the OR and the hospital. These are generally the people who have the best knowledge base and have worked closely with the surgeon and pick that person to do their surgery above all others. It is a womderful compliment of trust when the head OR nurse asks you to do thier childs surgery. I find it interesting then that a local surgeon spends much of his time acting as a professional expert in medmal cases. When I asked about him, the head nurse of the OR said, "Oh, he is a big poser!" I asked her what she meant, and she explained "He looks the look and talks the talk but I wouldn't let him touch a dead cat." "He is a soap opera doctor". After hearing this, I had to agree. He is at all the staff meetings and surgical committee meetings but I have never seen him in the OR. When I asked her about this, this said that he has to be at all them as a strong offense is the best defense. As to being a Medmal expert she said "he out to be good, as he is good at malpractice".

I could not help but wonder about more posers that I see, especially with all recent political unpleasentness.

Friday, September 26, 2008

Trauma score of 21

I just recently had one of those cases that just tears at your heart. Sometimes it hurts so bad that being cynical almost becomes a defense mechanism. I can't help but refer to one of the great tomes of Surgery, "A Chance to Cut is a Chance to Cure". From its chapters is the trauma scale. This is the trauma scoring system as related and handing down through Rip Pfeiffer M.D. and the veterans of Parkland with a few of my own added in. By calculating the total points received per patient the following guidelines were established in determining the patient's chance of surviving a major trauma. This system explains the reason why one chances of survival are inversely proportional to ones value to society. In other words why the minister dies and the gangbanger lives.

Chances of Survival

0-5 points.............................30%
5-12 points...........................60%
Greater than 12 points.......95%

Etoh level
100-299 2 points
300 or more 4 points
Injured while riding motorcycle
with helmet 1 point
without helmet 2 points
Arrives wearing biker T shirt 1 point
Patient comes from or going to jain 4 points
Spouse in jain 1 point
Arrives by helecopter between 1 and 5 am 1 point
Known by at least 5 people in the ER 1 point
Tatoo (1 point each, maximun of 5 unless homemade then add one additional point)
Tatoos/teeth greater than 1 1 point
Mis-spelled tatoo 1 point
Tatoo on face 2 points
Warrants for arrest (2 points for each, total 6points)
Emergency contacts listed on triage form (1 point for an attorney, 3 for bail bondsman)
Last bath more than 2 weeks ago 1 point
Has two children with same name 1 point
Previously shot or stabbed (2 points each episode, maximum 6)
Knows where the best veins are 1 point
Arrives with iv already in 1 point
Allergic to Kwell 1 point
Smokes more than one carton/day 1 point
Drinks a case/beer/day 1 point
Seeking disability 1 point
Allergic to Talwin, Codeine, Toradol 1 point
Covered in vomit (1 point if their own, 2 if from someone else)

Sunday, September 21, 2008

Stark Reciprocity

Pete Stark is a Congressman that seems to go way out his way to regulate the practice of medicine and every 6 months or so, he seems to turn yet another screw. This makes the practice of medicine more regulated than the practice of running a nuclear power plant. A friend of mine emailed me this. These are the Pete Starks laws applied to Congress. Mind you these are only a few of the Stark laws.

1. Every 6 months each member of Congress shall disclose to his or her constituents by first class mail delivered to the constituent's place of residence:
a. The amounts of each PAC or other political donation from each lobbyist or interest group b. The individual(s), businesses, or special interest group that donated the money c. Any personal consideration received from a lobbyist e.g., meals, trips, use of planes or other transportation, etc, and the identity of the donating party d. How the member voted on bills affecting each party listed in (b) and (c).

2. A member of Congress may not accept gifts or other consideration in excess of $100. This includes political campaign donations and PAC money.

3. Since a member of Congress is in a position to vote for legislation that could enhance the value of their own investments, no member of Congress shall own any investments of any type of kind, active or passive, except for a blind trust. a. Each member of Congress shall be allowed to own ONE piece of real estate property in addition to their primary residence. b. If a given legislative issue affects the value of property owned by a member of Congress, that member shall recuse him/herself from any votes that affect said legislation.

4. Compensation for members of Congress shall be determined by the American Medical Association and annual raises shall be less than the rate of inflation.

5. Health insurance for members of Congress shall be equivalent to the HMO benefits offered by Aetna for a typical medium-sized corporation.
a. All preauthorizations will be denied on the first request b. All treatment rendered will be considered experimental and therefore not covered by the policy c. No member of Congress shall be allowed to stay in the hospital more than 4 days.

6. If a member of Congress has a dispute with their health plan, they may only seek recourse through a federal lawsuit.

7. If a member of Congress (1) votes for something that turns out to be extremely stupid and ill-considered, and that (2) results in harm to the citizens of the United States, then (3) they may be sued for everything they are worth.

8. Every office for every member of Congress shall be inspected annually by JCAHO, CLIA, and OSHA. Any infraction shall be punishable by a f$10,000 per occurrence and loss of voting priviileges for 6 months.

9. Each Congressional office shall be given a 300 page manual concerning citizen privacy rights and shall be in compliance with each and every regulation

10. Any person, at any time, may file an anonymous complaint about a member of Congress a. The member of Congress shall be apprised of the ftact that a complaint has been filed. b. The member of Congress shall have no right to know what the complaint is about until the day of the hearing c. The member of Congress shall have no right to present evidence or testimony in their defense d. The member of Congress shall have no right to a fair and impartial hearing e. The member of Congress shall have no ability to appeal adverse decisions.

11. Never events a. No member of Congress shall become intoxicated b. No member of Congrehss shall have sexual relations with anyone other than their spouse or significant other c. No member of Congress shall add non-germane amend nments (riders) to any proposed legislation d. No member of Congress shal l have any local transportation paid for by the federal government (in other words, no limousines). They can drive to work or take public transportation like everyone else. e. No member of Congress shall fly other than coach unless the difference is paid for personally f. No member of Congress shall vote for anything that turns out to be the wrong thing to do g. If any of the above "never" events occur, the member of Congress shall not receive any pay for the year in which the infraction occurred

Munchausens' by Attorney

When a new patient comes to the office, we are required by insurnace and CMS to get all kinds of information from them. This is all the family history and past medical history stuff that takes so long. We just had a patient that came in the past medical history was seven pages long. It was filled with a list of things like irritable bowel, interstitial cystitis, fibromyalgia, chronic pain, depression, etc. All the things that are in the medical neverland that can not be proven to be real or non-real. When I looked at the form, I was amazed as she included in her Review of Symptoms, those that would support her diagnosis except that they were listed in alphabetical order and not the way they were listed above on the form. (we ask the patients to actually list their symptoms rather than just checking boxes because people would otherwise check everything. None of the symptoms related to why we were seeing her.

I couldn't resist so I ask our Front desk receptionist. She is really the one who runs the practice, she sees all and knows all, and in fact does it all. She told me that this patient had one of those handouts from an attorney that tells them what to list and how to list it so that later the medical records can be requested used for disability or for whatever they have planned. I was shocked, I asked her how often this happens, and her answer was that it was all the time, she said she did not want to tell me for fear I would spend too much time in the office banging my head into the wall. Then she goes, "here, you might like this!". When the patient was filling out the forms, she asked if she could photocopy it, and sure enough, I now had the attorney's handout in my hands. It was a cut and paste breakdowm of each of the "questionable diagnosis" and list of symptoms and where to put them on the forms. There was no attorney's name on the form however.

Three days later, the requests for the medical records came, it was of course from a local disability attorney. I made sure that the photocopy of the attorney's handout was included in the records.

Thursday, September 4, 2008

5 finger CO-Pay

Saddly, medicine is a business and we have to spend much of our time with concerns other than medicine. One thing that we do is monthly review our supplies and how much of what to order. It is amazing how many small suture scissors, pick-ups, guaze, gloves, tongue depressors and thermometers we go through. It is not that we use that many, it is that so many are stolen! We try not to put anything of value in the patient rooms anymore as everything gets stolen. We were losing small suture scissors at a rate of 11/week.

I try not to think about it as having your patient steal from you is not a good thing for a doctor-patient relationship. It is worse though when you catch the patient redhanded. I had patient say, "oh, I though they were disposable" even though they were not used and were not needed for the reason that they were there. From what we can tell, there does not seem to be any demographic difference between who steals from us and who does not.

The latest is that a patient was caught trying to steal the blood pressure machine, the problem was that it was bolted to the wall. She had three of the bolts out when I walked in.

Wednesday, September 3, 2008

Thwarted Darwinism

Traveling by air can be such a hassle but I have to admit that I am a people watcher and some of the best people watching occurs at the airport while waiting for a flight. I had a lot of time to kill and was wandering around the concourses when one of those things that sums up our society occured right in front of me. I was on one of those moving sidewalks where the signs say "stand right, walk left". I was walking behind a lady when she came across another lady who had piled her bag on the stand side and was standing in the walk side leaning on the handrail. The lady I was following said excuse me only to get a foul look from the other who was blocking the whole sidewalk. When she finally moved she said b*****. The lady that was walking turned to her and asked if she could see the signs. When she had gone the lady that was blocking the whole thing turned to another lady who was beside of her and said, "why didn't you tell me not to stand there?" All I could think of was this was our society. She could have said "my bad" or "sorry" but instead of owning the mistake turned and blamed someone else. I guess it should not have stuck me so bad, except that she was traveling with 5 school children as a chaperone.

There was slight justice, she was so busy yelling at others for her mistake that she missed the end of the moving sidewalk and went flat into the floor. Darwin was thrwarted though, only a slight bruise.