Thursday, March 19, 2009


Boy have I got to stop watching CSPAN! I cant help it though it is so rich in pathology. I was watching Rep. Barney Frank when he was discussing the A.I.G. issue. At first it was hard to get through his aphrasia and his velopharyngeal incompetence but when I closed my eyes it was the aprosody that was so striking! It is just like the responses I get when I catch a prescription drug abusers trying to convince us that they need pain medications in the ER for something that they dont have. Then in between questions he had classic Biot's breathing which makes me think that there may be hydrocephalus or at least something worthy of a mri and tap for opening pressure.

I know that I mentioned this before and I am sure that it is probably why the whole HIPPA law was enacted, but cant we make sure that every elected official has a complete physical and mental health exam before running for or taking office? I mean we can comply with HIPPA and keep all information private except to the election commission who could simply state, "you cant run because you have a brain defect on MRI". Oh, wait a minute, that would be discrimination and they passed laws agaist that as well. How then do you get rid of an elected official who has a major health issue that prevents his or her ability to fill their post? Are there guidelines and then who enforces them? I'll bet money that the amount of Senators with Lewey bodies on MRI would scare the pants off of us. What about the meds that they are on? Would you trust your representative if you found out that they take 1 mg of Xanax tid for anxiety, adderal for ADD and then Effexor for depression and that they have bipolar characteristics? We have already had a president with Addisons disease and associated steroid psychosis and he managed to put nuclear missles in Turkey and take us to DEFCON 4. How do we even know what the blood alcholol level is of our Congressman when they vote on bills? Is there routine drug testing? Do you even notice that Sen. Feinstein has conjunctival irritation and mydriasis? I hope that it is allergies and the result of her medications!

Back to CSPAN, Sen. Dodd is talking, does he have ocular hypertelorism?

Monday, March 16, 2009


(Blue on Blue) It was an amazing meeting for the AMA and rumors were rampant. One was confirmed today by the Amercian Legion. The Obama Administration is planning on changing Veterans Benefits in a significant way. Injuries that are acquired by military service will not be covered and treated through the VA. Instead, it will be out of your own pocket by your own health insurance! That is to say if you can get it! Part of a RPG in your back tends to be a pre-exisisting condition. I can just see it now. IED strike, mulitrauma make it to Balad oh wait, lets see, you are BlueCross PPO, let me see if I can get that pre-certed for you. Oh, this is out of network so it will cost you more unless you want to go to Ramadi! I wonder if the politicians who are thinking of doing this have ever looked at dog-tags. They have your blood type on them, you know, the blood that you are spilling for your country. Oh, wait a minute, they have never served in the military.

Is Healthcare a Right? Or a Left?

I was stuck in an airport and managed to catch a local radio show. I think it was the "Valentine Show". Anyway, I was struck by his statements about "the right to healthcare". It goes something like this. I am paraphrasing as I can not remember it exactly. "If healthcare is a right, and we are going to make the government provide our "rights" then lets look at some other things that also then should be "rights". Lets say, food. You need to eat. Clothing, you need to be warm. For that matter, heat then should be a right. Of course, a place to live should be a right as well. So, if healthcare is a right and we decide that the government is to provide it, then they should also provide food, clothes, and places to live on the taxpayers dime. But then, by forcing one group to pay for anothers healthcare, isn't that violating their rights? I guess for the "Left" a "right" means that it is something that you get for free or at least someone else pays for the bulk of it while a "Right" "Right" is something that you can go out and get on your own and the government should not get in the way.

Sunday, March 15, 2009

Teleprompter case

One of the hardest parts of the job is having to give bad news. This is especially true after exploratory surgery when you find out that the tumor is far worse than imagined and that it has spread extensively. (I think that the pathologists should have to talk with the families and patients, after all they are the one who really decided that the cancer was there). As soon as you walk in to talk with the family they sense what is going on. They know if it is good or bad. Sometimes it is hard to find the right words that convey the information and at the same time comfort. I would love to have on of those presidential teleprompters to take with me where others can sit back and give me the words to say and answers to the questions that I am asked. Change that, I would rather have those people that are sending the stuff to the teleprompter just talk to the family.

Saturday, March 14, 2009

Little lost Remoras

A group of our collegues has just merged to form a larger medical group. In the process they need to expand both their front and back office staff and placed several ads for help. They had a flood of applicants and were supprised by the number who applied that had recently been paralegals. Apparently there has been a huge number of lawoffs in our local legal community. I checked with a patient who is a realtor who always seems to have the pulse of the town and she said that "quite a few local attorneys have their houses on the market and are trying to unload them". I asked her why this was and she said that she only has some ideas but thought that in a bad economy everyone would be trying to sue each other and was supprised that the lawyer clients are looking to go to smaller cheaper houses. I guess like in any business, when money is tight, the first to go is the help, and that must be why the attorneys are letting their paralegals go. I wonder how much some of our states tort reform measures have contributed to this as well as our states recent increase in "legal malpractice suits"?

Friday, March 6, 2009

HIPPA'ed Intraoperative radiology

In a stroke of high tech brilliance our hospital now has all digital xrays. All you have to do is pull them up on the computers in the operating rooms. In the old days, you put all the films on the viewing boxes so that in the surgical case you could look over and see all the films. Now, you have to pull them up on the computer. Of course on the computer to look at the different films you have to just scroll through them. Oh, wait a minute. If you are operating you are sterile so you have to have someone scroll through the films for you! To add to the confustion, HIPPA is concerned that someone might accidentally see the films so the computer goes to sleep and you must re-enter the passwords to see the films every few minutes. This ties up the circulating nurse up as she now is the "mess with the computer nurse" in addition to other duties of constantly filling out the JACHO paperwork. Then of course, the computer decides to not talk to the server and crashes when it tries to autoupdate in the middle of the case. I never had the old xrays and ct films "crash" in the middle of the case. I did have one fall on the floor once. The nurse just picked it up and rehung it. When the computer crashes she has to reboot it, call tech support (in India) and spend an hour trying to fix the problem. The last case, I had to unscrub and go to radiology to look at the films on the main system because the whole thing had crashed. Of course it was an emergency case in the middle of the night. Aint technology wonderful, especially when the government gets involved!

Flaming Zombie

In order to comply with JACHO and to decrease infections our hospital has those gelled alcohol santizers everywhere with signs to encourage everyone to use them when they walk by. There are also signs everywhere that say "No Smoking". Of course no smoking is allowed in the hospital and you can imagine that the patients who smoke will drag their IV poles and pumps, scds and drains out the door and around the corner to the smoking area. You can gues what happened next. One of our regulars who was in the hospital drying out from a blood alcohol level of 0.37 had used the sanitizer on the way out and still had a lot of the gelled alcohol on his hands and had dripped some on his gown. When he lit up, he lit up! He tried to put the fire out on his gown and this lit. Luckily he was not badly hurt. (He had disconnected his oxyegen back in the room) I wonder if he had MRSA and if the fire killed it? Later we found out that the same patient had some of the sanitizer in his room and had been drinking it.

Generation that gave all and the generation that takes all

I met an older gentleman in clinic today. He was hunched over and walked with a cane. You could tell that he was in pain. Even though, he helped another gentleman into the exam room and held his coat. I looked at his chart, he was not on any pain mediations, only a daily aspirin. He put down that he takes an occaisional motrin for back pain. He was blind in one eye and had partial paralysis of his left arm. Talking with him, he has a farm and has worked there all his life. He apologized because he felt he was late for his appointment. One of his cows was having a calf and he had to help pull it out. With all his problems he was not on disability. I apologized to him because I was late. It turns out that he lived on the farm all his life except for the years in the Army and in the Japanese POW camp. The paralysis and the limp was from the shrapnel that is still in his spine. He lost his eye when he was tortured.

When I left his room, I went to the next. There was a 30ish year old woman on full Social Security Disablility for "chronic fatigue syndrome, fibromyalgia and interstitial cystitis". She was on Oxycontin, Lortab, Xanax and Adderall. At least that is what she put on her new patient intake. She did not have a referring doctor which is always a tip off that she is making stuff up because they dont want to have us check up on their records. The disability was real though. She had the magic money card. We got lucky though, she had some xrays at the hospital and we can access their file system. She had been doctor shopping to generate the paper trail to get her disability and then jumping to try to get each doc to refil her fake "home medications". I was in the room no more than 30 seconds when it came "I wont see my family doctor for several months, he is such a bad doctor, can you call in or give me refills for my home medications." I quitely explain that it is bad medicine to have multiple doctors writing for multiple prescriptions but I would be happy to call her doctor to see what can be arranged. I got the standard answer "My doctor is so bad, I am not going to go to him anymore, could you please refill my mediations?" The game goes on. "Do you have your prescription bottles with you?" "No, I left them at home." "What pharmacy do you use? We can call them?" "I dont remember." Now that this had wasted about 10 minutes, we get to the reason that she is there. She had been to the ER in the middle of the night complaining of severe pain and I was the lucky sod on call with whom they had set her up to follow up with. She did not like the diagnosis of musculofascial pain and the offer of motrin and demanded that I give her dilaudid for this pain that she did not have when she went in the room and all the questions about her home medications. On her way down the hall she literally walked into the first patient who could not get out of her way fast enough. She called him an "a--hole" and yelled "watch the F+++ where you are going, cripple!" even though she was the one who walked into him. Once she was out of the office she got in her car that was parked in one of the handicapped spaces and sped off. We helped our fist patient back to his feet and asked if there was anything we could do. "He said, I've seen worse." When he left we saw that he was parked about as far away from the office as ou could get. He held the door for several patients coming in as he was on the way out. There was a Corvette in the handicapped space and I saw a young kid hop out.

Thursday, March 5, 2009

Occam's Legal Razor

(Parsimony of payment) It all boils down to who has the most money. Recently there was a lawsuit against a drug company. The company made phenergan an antinausea drug that is routinely used around the world and is now generic an produces by many companies. A physicians assistant gave a patient an injection of the medication in an artery instead of a vein by mistake. The medication already has a warning that states it should be given slowly to prevent possible complications including gangreen and that it should not be given in an artery. Neverthelesss, the patient had severe vasospasm from the arterial injection and lost thier limb. So who was sued? You guessed it, the company that makes the medication, not the nimrod who gave it in the artery. A jury felt bad for the patient and awarded them 11 million dollars beacuse they felt the warning on the label should have been more explicit. This is even though the warning on the label said to not give it interarterially. Anyway, the drug company appealed claiming that it had complied with FDA regulated warnings. The Supreme Court now has sided with the plaintiffs. So, even though there is a warning and the original problem was caused by one persons error, our courts show that Occums Legal Razor ( go for who has the most money first) is the best option. So how do you have warning labels to protect you even when they already say dont do this? There is no way. Even when we look at idiots using phenergan in arteries, the rate of this complication is less that getting struck by lightning. Oh, wait a minute, they should probably have that on the label as well. "You may get stuck by lightning". Anyway, now every drug company will be sued about their labels because we have a precident. Phenergan which is now generic will not be profitable enough to make with the added liability and it will vanish like tigan and droperidol. So that leaves only Zofran and its expensive clones to use for our kids getting chemo. Unfortunately, these meds are very expensive and didn't seem to work for the kids like phenergan could. (phenergan is being pulled from the formulary) I guess this was a good case for attorneys but a bad one if you are a kid getting chemo.

Wednesday, March 4, 2009

Little League Eligibility

Just got back from my sons first Little League practice of the year. This year like the others we had to provide a copy of his birth certificate. This is to show his age and that we are not loading the team with foreigners of indetermate age. The certificates are on record so that they can be presented if challenged. I guess Little League rules are a bit more serious than our Presidental Candidacy rules. I wonder if our president ever played Little League?