Frivoulous Medicine?

One of the things that I love to rant about are what seem to be frivoulous lawsuits filed to drive the economics of the legal profession. I cant help but think that we in medicine are just as guilty. I mean, when I look at the surgeries that we do, only a small proportion are life and death in the sense that if the surgery is not performed, the patient will die as a direct result of their disease process. In fact, most of the surgeries are for pain or impairment in some way. The OR schedule if full of cataracts, elective hysterectomies, carpal tunnels and knee scopes.

The economics of this are amazing. We get paid more for the elective stuff than we do for the emergency life and death stuff. A 30 minute elective case pays more than the 4 hour cancer operation. I dont even want to go into the economics of all the medical tests! I guess the silver lining is that it is the elective stuff that generates the revenue that keeps the medical practices and hospitals financially afloat and the insurance companies flush with cash. I wonder what would happen if elective stuff had to be paid for in cash and not in insurance money? The problem with this stuff is the same as frivoulous lawsuits. They are not frivoulous for the person who wants the surgery or is filing the case.

Apex Predator Starvation

I was helping the kids with their biology homework and their lesson was on the health of ecosystems. One of the important points that was made was that you can see how the apex predators are doing to understand the health of the whole system. This is like saying if the sharks are starving, that means the fish aint doing well. If the sharks are eating each other, then you know things are bad.

So, I thought, lets look at our economic ecosystem and sure enough, the apex predators are starting to hurt. Abovethelaw.com is keeping a tally of all the big lawfirm lawoffs that are occurring right now. It also mentions how some firms are not giving raises to their first year associates (who make $180,000/year). (Pediatricians with 7 more years of education get about 80K!)

I just wish the apex predators were not dying off because of the economy but because the fish were better armed. In the mean time I cant wait until they feast on each other!

Federal Ponzi Scheme

Every time I hear about the Federal Bailouts in the news and then what is happening with Wall Street all I can think about is it seems Ponzi schemes are bad unless you are in the government. I mean in a Ponzi scheme, you convince people to invest with you and promise them returns, but the returns are actually from others jumping in to invest. You then skim off the invested money for your own purposes. Isn't this exactly what has happened with Social Security? The money from the original investors is supposed to be paid back by later people except that the money is being pulled away by the gorvernment. There are more people expecting to be paid from it than there are now investing in it.

The bailout is kind of the same. They want us to invest our tax dollars so they can skim them off for their own purposes with the explantation that it will change our economy and the future generations will pay it back. Isn't this also a Ponzi scheme. I am supprised that Maddoff is going to court instead of being put in charge of the treasury. Oh, that job was taken by someone who cheated on their taxes.

Freedom? of Choice Act

Barack Obama was a co-sponsor of the Freedom of Choice Act and has promised to sign it if it gets to his desk. This bill basically states that every woman has a fundemental right to terminate a pregnancy and that it "It prohibits a federal, state, or local governmental entity from denying or interfering with a woman's right to exercise such choices; or discriminating against the exercise of those rights in the regulation or provision of benefits, facilities, services, or information. Provides that such prohibition shall apply retroactively" It goes on to say that "It also authorizes an individual aggrieved by a violation of this Act to obtain appropriate relief, including relief against a governmental entity, in a civil action."

The long and short, "I want an abortion and if you dont do it, I'm going to sue!!" This is also tied in to all funding, so of course it is tied to Medicare and Medicaid so if hospitals refuse, they can lose all funding. As you can imagine physicians who oppose abortion are incensed. Cases have already been filed and won when an reproductive specialist refused to implant embryos in a lesbian couple on religious grounds. Apparently Freedom of Religion no longer applies.

So we now have a president who would rather try to force abortion than respect freedom of religion. It is going to be a very interesting year. I can only imagine what Catholic Health Partners are thinking.

HiB no, death yes!

You got to love Jenny McCarthy and all those that think vaccinations cause autism. HiB just killed an unvaccianted child and sickened 4 others in Minnesota. In our area we have had outbreaks of mumps including several with encephalopathy. Long Island now has outbreaks of German Measles including in pregnant patients. I cant count the number of chicken pox encephalitis that have been seen. Whooping cough is now in early epidemic stages and can be fatal to infants. For a while I think we could count on herd immunity but now I think that this is rapidly becoming a pipe dream. The media will take no responsibility for hyping the "notion that vaccines cause autism" they just do everything they can to sensationalize something regardless of its validity and hide behind "freedom of speech". I just hope that the resurgence of polio stays isolated because once you got it, there is no cure.

In our area, we have a large number of people who have come into the coutry illeagally and of course have not been vaccinated. In fact one of our local hospitals has had a whole group with active TB. The health department wants to track down who these people have been in contact with but of course they wont tell.

The good news is that many of the companies that made vaccines have be sued into nonexistence. If these recurrences of disease continue I expect that the remaining companies will be sued for not making enough vaccine available. After all, the media that started it will try to sensationalize that it is "Big Phama" that is to blame.

Censored medical records

Our hospitals don't have electronic medical records. All efforts at them stopped when the President decided to mandate them. What electronic systems we do have contain the lab reports and xray studies etc. Well, apparently we are getting a taste of what happens when the government gets involved in electronic medical records. There are now certain tests that the results are not listed in the electronic data system. They are censored. Even though only those who are actually taking care of the patient have access to the system, the government has decided that some medical tests are private and that the results should not be available in any record. One of these is HIV status. Knowing this status is very handy when trying to figure out why a chachetic patient has a pneumonia that isn't getting better or why he is having meningitis. They have even gone so far to make sure that the CD4 levels are censored so you dont even have a clue if they have HIV.

The other time they come in handy is when someone gets contaminated. We had a patient who was drunk who bit one of our nurses. Well standard protocol is to draw an HIV. Well, that information is confidential so the nurse can not find out if the patient had HIV. He/she just has to get multiple blood draws and hope that they dont get it over the next 6 months.

Is it going to be a morbidity or a mortality?

(morbitity and mortality moment) In training you had to present cases to all the other surgeons and surgeons in training any case that went wrong. Sometimes the cases were those were things were going wrong and you were called in when there just wasn't much that you could do. I had one of those yesterday. I got called stat to the ICU. A very complicated patient with an ejection fraction of 20%, bilateral pulmonary emboli, bilateral severe carotid 90% occlusion and recent mesentaric ischemia who had a respiratory code the prior week secondary to a mi was bleeding. She was bleeding just fast enough that we could barely keep her pressure up with a level one infusion pump. She was on coumadin for her clots. Blood was coming out of both ends.

We get the critical care team and then starts the big decisions. We seem to be maintaining her by keeping up with the blood. It does not seem to be slowing down. We can try to reverse her coumadin and give stymate but this might cause her to clot her coronary arteries or her bowel and that could kill her. As she bleeds, she is losing what ever clotting factors she has so at some point we will have to giver her FFP no matter what. Anesthesia feels that with her recent heart attack and her other conditions that we will most likely lose her on the table. In 2 minutes the decision is made, family is talked to as we roll into the or. With divine help, the bleeder is rapidly found and she makes it out the OR. We had to give ffp, platelets and stymate and she doesn't infarct. Once she is bact in the ICU, we talk to the family.

Then we get back to the lounge and start freaking out. She did well, but we got lucky. If we didn't find the bleeder rapidly I am sure that she would not have made it. These are the cases that land you in court. They are the D if you do and D if you dont. If she had a MI, an attorney would argue that we should not have reversed her coags, if she bled out, they would have an expert argue that we should have reversed them. If she died in the OR, they will say we should have stayed in the ICU. If she died in the ICU they will argue that we should have gone to the OR. It is a no win situation. The family had gone through the shock of her original problems and was seeing her get better, and then they see that she is suddenly about to die and immediately they jump to it must be some doctors fault. My relationship to them lasted the one minute they saw me run into the ICU. People argue that malpractice is when the standard of care is deviated, the problem is that the standard is whatever you can pay someone to say it is. When you have coin flip cases, no matter what you can get sued. All you can hope is that everyting comes out ok.

I am so glad that I still can say that I do not think of the medical legal bullseye on my back till after the cases are over. You still document and dictate everything though just in case.

Yersinia

On a more serious note, I saw a report from the Sun (Validity?) that a terrosit cell may have been partially wiped out by a yersinia outbreak (al-Qaeda in Algeria). I don't know what type but I can only guess that it is the pnuemonic form. I have to wonder if they were working on a weaponized form and that it got free. Pneumonic plague is very nasty because it does not require a vector and is caught from inhaling an aerosol of the bacteria. It then can spread rapidly from one infected person to another and can rapidly wipe out a population. Someone with it has a first symptoms of a bad cold and is spraying the bacteria with every cough and can infect thousands in the right place. The good thing is that it is usually sensitive to doxycycline if you can catch it fast enough. Chloramphenicol and streptomycin also work but you cant get them anymore (lawsuits!) I dont know about you but I think some doxy in the medicine chest may be a good thing.

Non Billable Hours

I love how every time you call an attorney you get a bill. I guess, I need an attorney to take call with me. Last week sucked. It isn't the hospital calls or having to go to the ER that really wear you out, but all the patient calls. We have a very good answering service and they make sure that patients are told that after hours we only accept calls for emergencies and acute post-operative problems. Infact, patients are told this as soon as they call the number. This does not stop them, however. Each night on call there is a flurry of people who call because they were seen years ago for one problem but now they have a cold and want something called in. It is amazing how many patients call becuase they want narcotics or Xanax. These are the real pateints and not the ones who just pretend to be a post operative patient who ran out of their pain medications and hoping to score a fix. The answering service screens the calls to the best of their ability but unless it is an administrative call like scheduling an appointment they have to put the call through because of liability issues. All patients of course claim that they are having an emergency or that their cough is a post-operative issue from their recent surgery (6 years ago). I really love the 2am call from a patient who has insomnia or constipation and has had it for months and chose this time to call. When the service rings the calls through I always answer with this is "Dr. Throckmorton what is your emergency?" They always answer, "well, its not an emergency but I was wondering if you could call in a prescription for my excema, its been really bad this month." When I actually get a post-operative call or a real emergency it is like a breath of fresh air.

I guess I understand that they dont want to come into the office, but why dont they at least call when the office is open? Instead they call at 3am Sunday night. I wish we were like attorneys and got paid for phone calls. I bet that would cut down on all these late night and weekend calls. We could charge for the start of the call and then by the 15 minute blocks. Even better, we could charge patients for a retainer fee just to take their calls. We could learn so much from attorneys! Then again, have you ever tried to get your attorney after hours or on the weekend?

EMR DOA

"To error is human, to really screw it up you need a computer, to screw it up beyond all possible chances of repair, you need a government designed computer!"

If you really want to get rid of a good idea, let the government get involved. This is what is happening with the EMR systems accross the country. Since the Obama administraction wants to mandate EMR systems, nobody wants to get one. This is because nobody has any idea about just what kind of system the government will mandate and of course every congressman will get involved to be sure that it has some pet issue of theirs so as a result there are no systems currently available that can be purchased that can meet the future over-regulated and Federally screwed up criteria. So, you don't dare invest the money in a system that you will have to throw away in a few years.

We as well as most of the physcians in our area who were getting EMR systems cancelled the orders as did our hospitals.