Saturday, May 30, 2009

Administrivia stat pages

It was a new record at our hospital this week. Within 30 minutes of admission of a patient to the hospital I got three seperate pages including one from a RN and another from the nurse manager that I did not fill out their newest JACHO form. 2 hours later when I finished surgery, I went to check the patient that I had admitted and found out that no nurse had yet been in to see them. Out of spite I filled out the form and gave it to the patient as well as a copy of the incident report that I filled out. I then recalled the nurse manager who paged me and told her that the form was in the patients room.

I cant fault the nurses on the floor. They were creamed. They are understaffed because so many of them that should be taking care of patients are now walking around with clipboards making sure that the paperwork is done, regardless of the actual patient care. We now have nurses that take care of patients and nurses that take care of paperwork and manage the administrivia. The more admistrivia they manage, the more they create. The more paperwork nurses we need. Since the hospital is going broke, they cant afford to hire more nurses. The result, less patient care and more administrivia.

So I get three pages regarding a nonessential paperwork form within 30 minutes and the patient with a severe infection was not seen for 2 and a half hourse and did not get his first dose of antibiotics until 4 hours after he was admitted.

Thursday, May 28, 2009

Homeopathic Waterboarding

In the service I was never waterboarded but it was demonstrated to us during survival school. It is basically forcing someone to lay back while you pour water over their nose and mouth to simulate the effect of suffocating. This causing an intense feeling of distress and panic. Much like using a Nettie pot, I found out. With one of these as much hyped my Oprah, you twist your head back and pour water into your nose while it spouts out the other side and down your throat and out your nose. Causing first much dread and panic with a little bit of suffocation. When I first did this to treat my sinus infection, I would have given up my social security number and ATM pin number to anyone that asked to not have to do it again. But, do you know what? It worked! My head was as clear as could be. In fact, I did it again, this time I held my breath and it was much more tolerable. Now I pretty much waterboard myself whenever I have sinus problems.
I am now working on other homeopathic medical treatments we can use on Enemy Combatants. Maybee we can put lit candles in their ears! Force them to drink urine? Or, the worst, herbal colonics! Tell us what we want to know or you will have lilac flatus!

Sunday, May 24, 2009

Lateral Boomerangs

The perfect administrative federal healthcare medicolegal storm seemed to hit this weekend. Medicare has a whole bunch of diagnosis that it will not pay for if a patient is discharged and then is readmitted within a certain peroid of time. Because of lawsuits and threats of lawsuits our nursing homes and extended care facilities are decreasing in number and want nothing to do with complicated patients. This leaves as the only option home care and home health for those patients that do no meet Medicare admission criteria anymore but cant get into an extended care faclility. So many go home and then need to be re-admitted. So what do you do. The answer that comes rapidly is to re-admit them but at another hospital. A so called lateral. A lot of folks went away for the holiday weekend, so what do you do with grandma? Just take her to the hospital! She was just there 2 weeks ago for her COPD exacerbation, they will admit her for a few days while we go to the beach!" Since she was just there and was dumped at the ER you have no choice to admit her, but then the shell game starts. Doesn't her internist also have privaledges at the other hospital? And so goes the lateral.
The long and short of it. Medicare wont let you keep them in the hospital. The nursing homes and ECFS wont take them because of liability and lack of pay, so you discharge them and readmit them to another hospital. Welcome to the world of federally managed healthcare.

"That Others May Live"

"That Others May Live" is on the emblem of the finest men and women to wear the uniform of our armed forces and in no way to I equate the events of today to their mission and sacrifice. I am very proud though that there are other Americans who who jump in on the civilain side to help others.

As we drove back from visiting a relative in poor health, we saw a tragic site. Some motorcyclist were riding side by side behind several cars. As the cars slowed down to take the exit the motorcyclist found themselves too close and one of the bikes went down on the interstate and flipped. We immediatly pulled to the side and ran to help. Car after car stopped and people jumped out to render assistance. One man ran into the interstate and directed cars away from us as we held pressure and held the motorcyles passengers neck in line. Another man ran into the road to save the motorcycle's driver who in his post concussion was walking right into the traffic. All told we had at least 10 people there is less than a minute. There were 4 nurses including one from our trauma center, 2 physicians, an off duty EMT and three others who risked the high speed traffic to help. EMS was there in a few minutes, the same gentleman who ran into the interstate to save the driver directed the traffic to clear a lane for the ambulance. The rider and his passenger will be OK, rain will wash the blood off the road and others will go home after putting their life on the line to save anothers.

Thursday, May 21, 2009

Not the Disability I wanted!

How come if you are "legally completely disabled" you still get to drive? Today I had yet another disablity form cross my desk. We tell patients ahead of time that we do not fill these out as we are not qualified to determine disability. When the patients ask me why I am not qualified I answer that "I dont know why if you can drive why you cant get a job as a driver."

Wednesday, May 20, 2009

Oops, I did it again!

I think that if you are suing the trauma center and the docs that saved your life, you should probably move to another city before you get shot in another drug deal. One of our local unregulated pharmaceutical distributors managed to get shot 7 times. The trauma team pulled him through but of course he has filed several lawsuits against the medical center claiming everything from chronic disabling pain to loss of consortium due to "negligence" of the doctors and not his GSWs. He has even managed to get full Social Security Disability. The suits are bogus but of course they are a slap in the face to the docs and still represent a huge pain in the neck. The guy is just trying to see if he can be a big enough pain to get some settlement.

Well, as luck would have it, he managed to get shot again in another drug deal and was brought right back to the trauma center where the group of docs that he is suing had to save his life again. Traditionally, trauma patients are entered into the system for their labs and xrays by a code name until their real name is known. He was recognized immediately by the ER staff. Rather than using the standard trauma name from the list, they entered him as Plaintiff Plaintiff into the computer. The doctors and nurses of the trauma center now refer to themselves as co-defendants.

I would hate to be in the intensive care unit with the docs and nurses who I am frivoulously suing in charge of my sedation and pain medication.

Sunday, May 17, 2009

Pretend Doctors

This has been a long call week so I am pretty fried. Several of the emergencies that I was called to see where the result of pretend doctors for which it seems we are seeing more and more. The first was a patient with mylodysplastic syndrome that makes what little platelets he has not work well. When he went to get his pain medication filled he was told by the pharmacist that he could also take aspirin or ibuprofen to help with the pain. Of course, this made the few platelets he had not work and came in bleeding. When I asked the patient why he took the aspirin, even though he had been told not to, he said "the pharmacist was a doctor! "

The very next patient came into the ER with severe back and shoulder pain. He had been seeing his independent nurse practicioner for a large swelling on his shoulder that did not get better with the multiple courses of antibiotics. The back pain had been getting worse for months. Our xrays showed that shoulder mass was a metastatic tumor as was the tumor that had eroded the body of his T6 vertebrea causing his severe back pain. Turns out he had been having hemoptysis a few months ago and the same NP treated it with antibiotics for his cough. His lung cancer is unresectable. We tried to get medical records from the NPs clinic. They do not answer the phone on the weekends or have an answering service.

The last case was the one that really broke me. A really nice gentleman who came in to the ER with generalized weakness and headaches. He was really proud that he had never had any medical problems and he attributed it all to his holistic lifestyle. In fact he goes and sees his holistic physician once a month. They had been trying all different types of therapy but he was getting weaker and weaker and ended up in the ER when he fell. His EKG showed AFIB, his ejection fraction on echo was about 20% and his lungs were full of emboli from atrial clots. His histrory was a bit hard to get as he had to breathe with the rebreather.

I know that there are good nurse practicioners, good pharmacists and good holistic practicioners out there. I also know that there are bad doctors out there. What I think makes the ones that are good, good is that they know that something is out of their league and they get help. Hopefully, they get help for their patients before its too late.

Sunday, May 10, 2009

He spent all my money and all I got to keep was the loose "CHANGE"

I could not help but feel the irony that this week the President announced that he wanted Americans to be responsible for their credit card spending and to not live beyond their means. He also then stated that he wants a bill of rights for the credit card users. Didn't he just max out the country's credit, put our grandchildren in debt for it and then change the tax code to stick it to us?

He took all of our tax money, plus that of our children and spent it all. The good news is that some got $500 back. The loose change of the $100,000 plus that his budget will put us in debt. Perhaps in that "bill of right for credit card users" it could include a statement that "credit users shall spend as much as possible with no consideration of limits and all amounts due shall be payed by others until their and their childrens assets have been exhausted."

Saturday, May 9, 2009

MRSA and Expatriate American Ingenuity

I an very excited that there are actually some new antibiotics in the pipeline. Even better some of these are showing great efficacy against the resistant MRSA and other severe pathogens. Several teams of American researchers have discovered this whole new class of antibiotics as well as a bilological way to mass produce them. The only problem is that they are leaving the US to do it.

Because of the risk of litigation and the enormous costs to get these medication on the market no company based in the US wants any part of them. In fact, to limit liability, it looks like these will be made by smaller comanies located off shore in countries with better liability protection. Further, these drugs will be available in those countries long before they will be here due to all the FDA regulations.

In an even bigger twist. At least one of the new antibiotics will be made in Canada but will be exported and not used domestically. Further, it will be exported though a small Ltd. export company with little or no assets to further decrease liability exposure. Production is also expected to begin in several other countries to decrease taxes.
So, we have potentially life saving medications that are developed in the US but because liability, taxes and regulations it is better to leave the US with them.

Somehow I doubt that that we will see a solution to our regulation, taxation, litigation stifling of Amercian Ingenuity soon. In the meantime, I wonder if instead of calling these "new antibiotics", they could just call them "Nutritional Supplements". That way we could just order them from an infomercial to help save our patients?

Attorney(Commercials)/Pharmaceutical(Commercials)= 9

I had an administrative day yesterday to prepare for some lectures to the medical students and residents and to catch up on the huge pile of neverending non-patient care paperwork. To keep my ADD in check I had the TV on in the background. From 12 noon to 4pm I kept track of what type of commercials were being aired. Since most of the channels go to commerical at about the same time, I would flip at commercial breaks to keep track of the commercials. In that period of time there were 28 commercials that I found for trial lawyers. There were three from pharmaceutical companies. Of the 28 lawyer commercials all but six were for medical devices or drugs. The others were for asbestosis. The drug commercials were all for menstral irregularity. The shows that had the highest concentration of lawyer commercials were Oprah and Dr. Phil. All the drug commercials were on during Oprah. I wonder what this says about the demographics of who watches Oprah? If I just look at what industry was spending the most on advertising during this time peroid, it was the trial lawyer industry.

This was in no way a formal study, but I would sure like to see one. Better yet, I would love to see a report of the adversiting demographics that the trial attorneys go after.

Wednesday, May 6, 2009

The "its not my money test"

I had two patients in the office today with the exact same complaint. I explained to each that it will usually get better with time and if necessary some anti-inflamatory medications but given the severe I could not rule out anything bad and that a MRI would help rule this out. One patient had United Healthcare and explained that he would have to pay 30% of the scan upfront and since he has a huge deductable he wanted to see how his symptoms were and that he would get the scan if things changed. He could afford the scan right now. The other patient had Medicaid. When I explained the same things to him, he jumped right up and said get the scan, "after all its not my money!"

As I mulled this over, I wandered to the doctors lounge. There several of the other docs were having a discussion about healthcare costs and wondered why have health insurance at all? Why not universal governement health coverage like Medicare and Medicaid. I couldn't control my usual introverted quiet self and let go.

I explained that people spend more carefully when it is their own money that they are spending. Like the difference between the two patients that I saw earlier. One of the docs immediately pointed out that one got the MRI where the other didn't. I told him that this does not mean he got the best care, it just means he spent the most money. As people who are disconnected from the cost spend more and more, suddenly there has to be cuts. Since it is not your money, the people whose money it is (Government) will then decide on how its spent and will have to limit it. With private insurance you are contracting for and paying for future care and have some control of how that is spent. Its your money not the governments that is being spent. The nephrologist jumped in and explained that he was doing dialysis on a patient from Canada who was here to have her CABG because she could not have it back home.

So, we can give the government our money, they then make that money theirs and they decide how it will be spent; or we can save or use our own money to help pay for the care that we want.

Sunday, May 3, 2009

Chrysler Care

People aren't buying the big cars and SUVs in these economic times, these were the products that brought in the proffit that offset the lossed in the other areas of the car business. The same is true for medicine. It is the elective procedures that pay the bills for most hospitals. These are the ones that are covered by the private insurance and provide the profit that allows for all the care of the life threatening conditions and the care of those who can not pay. As the economy has tightened so has the medical market. People are holding off on having that hysterectomy, cholecystectomy, knee scope, hernia etc. In many ways our medical system can be defined as a system where the profit from one group (Private Insured) offset the care for those with government insurance and those with none. The people with private insurance are not spending and as a result of the economics, the rest of medicine is starting to collapse. Two of the seven hospitals in our city are closing and the remaining are restricting their services.

Chrysler like the other big three had huge entitlement burdens that they could not shake. It had a huge tax burden that its foreign competitors did not have and regulations up the wazzo. As the economy declined, it could not survive. The government stepped in, gave it billions of dollars and did nothing to the taxes or the entitlements. It still failed and those billions are gone. They now want it to go bankrupt and merge with a Italian company that has failed many times and now is a constant failure supported by the bankrupt Italian Government. Italy supported the company by raising taxes and entitlements and now they have huge emigration of their young out of the country. Obama wants to raise taxes and increase entitlements here.

Medicine is like Chrysler. It is plagued by huge entitlements, regulation and taxes . Obama wants to change healthcare like he did Chrysler. He wants to increase the entitlements and wants to raise taxes to pay for it. Given what he has done for Chrysler I wonder how long it will be before he bankrupts medical care.