Thursday, April 30, 2009

Foxholes and ICU's

This was a tough week. I was asked to consult on a patient with with a severe infection. Since it is a Catholic hospital, there is a morning prayer that is said on the PA system each morning. One day on rounds she was spouting off about how the religion is for the weak minded and they needed to shut that D**** prayer off. I asked her what she meant and she said that she didn't need some relgion to tell her what was right or wrong, experience and the world told her what was right and wrong, "those Christians are all hypocrits!". "God was for fools". I kept my thoughts to myself, but could only imagine the irony that she was being taken care of for her IV drug abuse complications by the very people who believe that God wants them to care for all his children. Her endocarditis seeded her lungs the next day with septic emboli. She wasn't going to do well. She was transferred to the ICU. I saw her as the ICU team was getting everything ready to intubate her. She held my hand and with all the breathe she had left asked me to pray for her. I did. Her request were her last words.

Tuesday, April 28, 2009

Obama Orders

Instead of writing very specific orders for patients under my care for which I will be held accountable not to mention having to know what to do, I decided to try Obama CIC orders. I wrote in the chart that if the nurses felt that the patients life was in danger they could use medications and other skills to help the patient. I made certain that I left everything up to them and made sure that they would be accountable. Further I made sure that I made it as vague as possible. Just kidding.

I wanted to find out what my friends who were still active duty thought of the whole Pirate affair and how it was handled. The consensus was that "thank goodness that the Navy and the SOP Command had the courage to take matters into their own hands". Needless to say, they felt that the lack of clear direction and intention was a deliberate pass the buck by the President. Worse, right after the action the White House released a statement that the President authorized the rescue attempt when all he did was avoid making a decision and left it entirely to the Navy. They all agreed that the true Commander in Chief was the Navy commander of the scene.

Friday, April 24, 2009

The Too Sick to be in the Hospital Test

You have got to love it when the government runs things! Medicare will not pay for a pet/ct unless it is done as an outpatient. So if the patient is really sick from their cancer and is in the hospital, they cant have the test even though the results of the test will help determine how best to treat them so that they can get better and leave the hospital! I wish the politicians who come up with these policies had to come down and explain it to the patients and their families. I know that it would be evil for me to think that someday they are the ones who need the pet/ct and cant get it.

Wednesday, April 15, 2009

Legal Medicine

With the ferrocity that our trial lawyers defend our present tort system, I though well, if it is so good why dont we apply it to our medical system? WhiteCoat has an excellent report of it at his blog. Just think of it. If you have finances and the wherewithall when you are sick, you can hire the best consultants for your case and if you win your battle with sickness your doctor(attorney) would then be entitled to at least 1/3 of all future earnings plus expenses. Of course, your actual care would be determined by a group of your peers who have been carefully selected to weed out anyone with medical knowledge or higher education after years of trivial motions and billable hours. The insurance companies could then hire their own doctor(lawyers) to argue the opposite. Since this is now like our tort system, if you do not have any resouces you must find a doctor(lawyer) willing to take the case but if there is no money in it, you are out of luck. On the otherside you can always try to file for a frivoulous care in the hopes of making it big. You know like getting a liver transplant when you just need your gallbladder out.

The good news, Obama is a lawyer and so is most of his team.

Thursday, April 9, 2009

Facultative Anaerobe

Went to see a consult today. The patient is a 120 pack year smoker. (number of packs of cigarettes per day times number of years smoked) who is 57 years old. As I was explaining the surgery to him between his constant snorting of the oxygen from the nasal canulas he explained that he was just waiting for his check from his lawsuit and it was his old boss that caused him to be short of breath.. I couldn't help but ask what the lawsuit was about and it was of course for mesothelioma. I asked how he found out that he had mesothelioma was and he said that he answered an add on television and and the law firm set up an xray and it showed that he had it. The lawyers also said he got it from work when he was summer help at a brick factory. He even commented that he had only worked there 2 weeks. I asked how long ago this xray was and it turned out that he had the xray about a year ago. I asked if he had a ct at that time or a biopsy and he said that they said that he just had a little bit but it was enough for the lawsuit.

Well, being the good doctor I checked all the xrays we had on the patient including the many cts of his chest that he had for his squamous cell carcinoma of his lungs with positive hilar nodes. Nothing in the scans resembled meso. I checked the records, he had come in about 9 months ago with hemoptysis when the nodes and the lungs hits were found and had his first runs of chemo and radiation. Given the extent of his disease at that time, I would love to see his "mesothelioma xray" to see if those nodes and masses were there.

After I looked at the scans, I thought about going and telling him that his scans did not show mesothelioma but he was out smoking.

Wednesday, April 8, 2009

Logan's (Obama's) Run

How do you save healthcare dollars? Dont take care of patients. A group from the AMA just met with Zeke Emanual who is Obama's right hand man for healthcare. Zeke started off the conversation that he wants physicians and the AMA to go along with his plan or face a 21% cut in Medicare. Although the "healthcare plan" is still on the drawing board, the Obama administration has focused on cutting healthcare costs by decreasing the end of life costs. In general, about $55,000 dollars are spend on healthcare costs in the last years of life. This is critical care, chemo, surgery etc. that are used to prolong life from cancer and other chronic or severe conditions. They want physicians to "sway" patients and their family away these treatments to save money. They further want to appoint a panel to determine what cases and care that they feel are futile. In a sense, they want what they have in europe where no one gets dialysis after age 65, the elderly with pneumonia are allowed to die and a broken hip is a death sentance.

I am not supprised that the Obama administration wants to be the ones who decide who should live and die after all they are proponents of elective abortion and Obama is on record for saying that a baby that was born during a botched abortion should be allowed to die because of its cost to society.

When I heard all these things that Zeke wants to do, I thought at first he was only saying that Medicare would not pay for these treatments. Unfortuantely, Obama plans this for all healthcare costs as he makes the care priciples universal to all payors. Even when you are spending your own money. I guess he also wants to save Social Security as well by allowing all those old enough to get it to die of treatable things before they have a chance to collect.

I was really glad to hear that a physician told Emanuel that we as physicians work for a patients and not for the government, unfortuanely it seems that he wants to change that as well.

Sunday, April 5, 2009

Call Pay

It has been one of those weekends. It seemed that every few moments either the beeper was going off or I had to run to the hospitals. As my beeper was going off yet again in Bible study, one of my class mates made a comment that "at least it was good for the bottom line." It then dawned on me that he had no idea how doctors got paid. In fact, it seemed that most people did not have any idea. So I though I would give some of the answers.
We do not get paid by the hour. We do not get paid to answer pages or phone calls. For example last night I had several calls were people were just hoping that I would call in medications for them even though they had never been seen in the office. We do not get paid to answer calls from the ER. We also dont get paid to see patients in the ER. (If we are lucky and then have insurance we may be able to bill but this weekend I had 14 ER hits and only one had insurance.) That means that the other 13 were for free. In order to have hospital privaleges and to comply with EMTALA and COBRA we have to see anyone whom the ER calls us to see, and we have to see in follow up anyone that the ER sends us. So, as a result all this is usually for free and it costs us our time, staff and supplies. The patients of course then can always sue us! By law, we can not write off on taxes any of the free care that we provide. (Lawyers can) We only get paid when we can bill from insurance or in the rare case that the ER patient actually pays us. For the trauma patients who we don't get paid we also get the joy of having to cut our clinic schedule to be deposed as they try to sue each other and everyone else they can.

We get paid by clinic billing for our insured patients. So, we get paid to treat migraine headaches in clinic, not to take care of the girlfriend of the meth head who stuck her in the head with a steak knife at 3 am. We dont get paid to take care of the drunk who tried to play frogger and run across the interstate during rush hour. We dont get paid to take care of the illegal immigrants who were shot when they tried to invade someones house. We dont get paid when they come in the office and insult our staff, steal our supplies and the demand narcotics.

I though about how to answer my class mates "bottom line" statement, and just said, "it is good for Gods bottom line". Call isn't about the money, its about doing what is right.

Friday, April 3, 2009

Geithner Syndrome

I was wathching Timothy Geithner's interview with Katy Couric and noticed that he always leans forward with his shoulders bent and looking up at who he is talking to. I checked and this is how he was during the Congressional Hearings. Infact, I can not find a single video or picture of him with his head in anatomic position. I have got the feeling that he has a high c-spine abnormality and that he can not extend his neck to neutral. He also aways turns slightly to one side so that he can twist his head when he is talking which to me suggests that this is a fixation problem, most likely at the atlanto-axial level. The other thing that I noticed is that he has very delayed blink reflexes. Even with the hot lights of the interview, he blinked at a rate of 1/3 that of Couric. This is definately suggestive of some major medication or CNS issue. There is a lot more going on with this guy then we are led to believe.

Thursday, April 2, 2009


We had a patient in the ER with SVT that was a bugger to slow down. Apparently he was having an asthma attack and went to use his inhaler. It was of course one of the new $60 inhalers that most of our patients can not afford. He used it but could not feel the spray so he used it about 20 times and managed to get himself a bit toxic. Our great leaders have determined that to save the ozone of the planet it is best to get rid of the CFCs that are used in asthma inhalers. This is all part of the Montreal Agreement and as a result CFC containing inhalers can not be sold as of April 1st. The new inhalers to comply with this are very expensive and as a result many patients can not afford then, nor are they covered by insurance. To add to it, the new inhalers use a propellant that can not be felt when they are used which is very disturbing to those about to suffocate. Somehow, I dont think asthmatics are responsible for ozone depletion.