Friday, September 25, 2009

Closing the Door for Taxpaying Citizens

I was up in the trauma ICU making rounds when we got the word that we were on divert for trauma due to lack of beds. Since we are the only level 1 trauma center for a huge area this is a big deal. I looked glanced at Fern the ward clerk and before I could even ask she said 18 between here and the SICU. This was the number of illegals or "undocumented" as the Feds say filling the ICUs. She then added there are 33 altogether on the trauma service. (There were three with the same name and same drivers liscence number but that is a different story.)
I would love to bring together the ACLU and our Congressmen and make them be the ones to explain to the greiving husband why his wife, mother of their three kids, school teacher and taxpaying citizen had to be sent 3 hours away while she bled to death because the Trauma Center that is payed for by her tax dollars that could have saved her life was too busy taking care of illegal immigrants. I wonder if he would feel consoled by the fact that the illeagal immigrant, drug dealing, gang banging MS13 member who took the last bed in the ICU was going to be fine as were most of the other illegals that filled the trauma service.

Thursday, September 24, 2009

Send in the JV

(Junior Varsity) Despite my best efforts, I am still on the medical center's quality review committee. At our latest meeting we discussed the problem of transfers that are coming from outlying hospitals that turn out to have a totally different diagnosis than what the transferring ED said they have. An example of this is when the outside ED calls and says they have a patient with a bad pneumonia and when they get to us we find that they are actually in cardiogenic shock from a massive MI, not pneumonia and the TPA window is passed. Our physicians are irate with these transfers but because of EMTALA they cant refuse them so they are stuck with the misdiagnoses and mismanaged train wrecks. So anyway, we looked into the issue. What we found was that these EDs have independent practicing ARNPs not docs. This was not the first time this issue has come up in the quality meeting, so the medical centers attorney was there to explain again how under EMTALA we just had to accept the patients and suck it up no matter what. Fuming at the the bad care that these patients were getting at the outside EDs I blurted out, "if we mismanaged and misdiagnosed patients like that we would get our a++ sued off!". To this the medial center's attorney explained that the ARNPs are held to a different standard. A lesser standard. I had to ask for clarification " so, if you come in to the ED and are seen by an ARNP there is a different standard than if you are seen by a MD or DO? Why isn't there just a standard for what problem that you came in to the ED with?" I didn't get an answer. I guess what I learned is that if you go to the ED with shortness of breath a DOC is held accountable for making the right diagnosis and performing the correct treatment, where a ARNP is not.

Monday, September 21, 2009

Want Ad

It seems that our rural hospitals are having a hard time finding general surgeons. I wonder why.

Wanted General Surgeon to cover small rural hospital.

Must have high school diploma, completed bachelors degree and four years of medical school followed by five to seven years of additional training. Must be able to work 50 to 80 hours a week and be on call all evenings and weekends. Must employee at least 6 others and provide malpractice insurance costing $200,ooo/yr. As a small business must also pay all self employment taxes and all retirement costs. Must be further able to support plaintiff attorneys and serve as a target for several frivoulous lawsuits/year. Must take all patients referred by the ER regardless of their ability to pay and be subject to government regulated pay, audits and fines. Pay is irrevelent to experience and consists of what is left over from all above.

Saturday, September 19, 2009

Medicolegalspeak Reports

Oh, I miss the days when you got a radiology report that said, "fracture right 3rd rib, no pneumothorax". Because of frivolous lawsuits radiologists have learned to be vague, noncommital and to pass the buck of possible litigation. So now you get a 2 page report that says "linear lucency in right 3rd rib, clinical correlation recommended, underinflated lung fields can not exclude underlying intersititial disease and or masses. CT recommended for futher evaluation, if condition warrants." along with several other paragraphs of lawyer imposed legalmedspeak. The radiologists are not the only ones who are protecting themselves from possible lawsuits. Pathology is right there. Once a lymph node biopsy they used to say "node consistent with reactive process". Now they give the ratios of the B and T cells and dont even bother to tell you what they think it is, you have to decide and therefore assume all the responsibility. Aint it great. We think we are the surgeons but the radiologists and pathologists have learned to amputate themselves from the disease of "joint and severable lawsuits".

Friday, September 18, 2009

O'bait and O'switch

I just saw that the President may be not have lied when he said that he would not give free healthcare to illegeal immigrants. It seems that he is planning to just legalize them all so not only can they get free healthcare but they will be able to get social security, wellfare, disability and every other entitlement that he can offer.

Water Glass Sign

(Some delusional patients are very prone to suggestions. The best are those in DTs. You can hand them a glass of water and ask them what color the liquid is and they will answer every color you can imagine even though they can see that it is just a glass of water.)

I had to go to the board of trustees meeting for the medical center. The trustees are an interesting group, some are local businessmen, several are in politics and one is very wealthy thanks to his inheritance. He is a proud fixture of the local democratic party and a major donor for them. I usually like to sit next to him just to see if anything is sinking in.

Anyway, the meeting's purpose was to explain why the medical center was shutting down most of its community outreach programs such as the diabetic teaching centers and local physical therapy centers as well as decreasing its overall staff. It also explained why it was shutting down two of the outside local satellite hospitals. Of course this created an uproar and the trustees wanted to know why.

Out came the numbers. Although the overall number or patients for all areas of the medical center was increasing (inpatient, outpatient and ancillaries such as diagnostic) the ratio of government insurance to private insurance was increasing. Simply put, the hospital was seeing more people with government insurance than private insurance and was therefore going broke. In fact, the center was losing money hand over fist. Even though it is seeing more patients, since they had Medicare or Medicaid it cost more to take care of them than they got from the government.

As this information was being digested by the trustees, I looked around to see the 3 Democratic politicians in the room. They were squirming a bit in their chairs. Before I could even look at Mr. Trust Fund, he spoke out and said it will "all be better with Obama's health care plan once we have a "public option". He said this after we had just seen graph after graft showing that the more goverment insurance we got, the worse we were! I wanted so hard to ask him what color the water was in his glass!!

Wednesday, September 16, 2009

Flu do, Flu dont

You have to love the government how they come through in a crisis. In our area the H1N1 is rampant. Infact, our ICUs are full of young people with flu associated pneumonia. So, in the interest of public health the government came out with several policies. First, to cut down on the spread, they announced that if you have flu symptoms to stay home, they also came out and said that if you have the flu to not go to the Health Department Clinics as the flu is self limited and this will decrease the chance of people there with other problems will get the flu. They also suggested that you avoid the hospital ers and doctors offices. So, guess what happened? If kids miss school, they have to have a doctors note. Since the flu lasts several days, the feds require FMLA paperwork from the doctors office for adults. Both of these require that the patient be seen either at the health department of a doctors office or hospital. So, they tell you not to go to the health department or doctor but demand that you do so for the paperwork. It is insane.

Saturday, September 12, 2009

I-Phone uninsured

I get a bit of time to write between cases while on call. It is often in these wee hours that I have time to ask the really hard questions that come from careful observation. Tonights is this. I have taken three patients to the OR tonight for urgent conditions. Each is uninsured, yet all three had the latest Iphones. Infact, one was looking up his condition on Google with one in pre-op. I dont have an Iphone because I thought it was too expensive and then you still had over $150 dollars/month for the sevice plan. I wonder what kind of catastophic health insurance you can get for $150/month? Anyway, it just seems obvious that no matter how cheap you make health insurance there will always be other things that people would rather spend their money on and still wont pay for it no matter how much it costs. Who knows, maybe the next big bill in Congress will allow for a government Iphone option.

Mama Bama's

(After Michelle Obama's policy where the University of Chicago hospitals dumped patients from the ED to nonexistent "community medical clinics" while she served as Executive VP and called it a "Community Outreach Program") I really hate patient dumping and this week on call is no exception. It seems that our ED becomes the one that outreach is to. As the hospitals are going broke, the dumping seems to be increasing and the hospitals are now very good at finding ways around COBRA and EMTALA just like Michelle Obama did. The result is that the patients have to go somewhere. One of the misconceptions is that these dumps are patients are the ones without insurance. Actually, they usually have insurance. It is almost always Medicaid. The hospital administrators know that the more Medicaid they get, the less likely they will be financially solvent so they have to find somewhere else for it to go and to make sure that it doesnt get into the hospital. I think it is rather funny that the President who clains that insurance companies shouldn't cherry pick their patients is married to someone who did just that. Seems she understood that hospitals cant survive on government insurance. Anyway, the game is to get the patients just enough better that they dont have to be admitted to comply with EMTALA and then tell them if they have any more problems to go to the "hospital" or "clinic" down the street!

Saturday, September 5, 2009

Draw the Rainbow

(When you dont know what is wrong with the patient, you draw every color blood tube you can find and send it to the lab for pan testing) I was supprised when on another blog a surgeon stated that he never had any problems with Medicare approving anything. I guess he either does not follow his patients in the hospital of that he has a very restricted practice because we run into it all the time. The usual situation is a patient who has sustained either a severe trauma or horrible infection that requires long term hospitalization. You get them through the acute phase but then there is the long recovery. Medicare will not cover the hospitalization after a certain peroid so then you try to get them to a "longer term rehab bed" but Medicare limits this. The patients only get so many days. So, you end up with the constant dilema. The patient is not well enough to be discharged but according to Medicare is not sick enough to be in the hospital. Before we could come up with some fuzzy diagnosis like "failure to thrive" or some such but that doesn't fly anymore. If you discharge them to a nursing home (Medicare wont pay for that either) and they come back to the hospital, Medicare counts that against you. So, what do you do? You have to come up with a diagnosis that Medicare will accept to keep the patient in the hospital that you can support with a lab or test. We use to just draw a UA or get a chest xray because we could always find an asymptomatic urinary tract infection in an elderly female patient or at least a questionable density on the chest xray to support a questionable pneumonia. But since these are now not reimbursed diagnosis by Medicare as "hospital acquired infections" they do not count. You see our goal is to keep the patients in the hospital until they are well without the patient and the hospital going broke. So, now we draw the rainbow and hope to come up with a documentable diagnosis to keep the patient in the hospital. If you draw enough blood for testing, the patient becomes anemic. Severe anemia is a Medicare approved reason for hospitalization!

Friday, September 4, 2009

Fem-pop, chop chop

I saw that in a speech in N.H. last month our President stated that physicians would rather cut off a leg than treat diabetes. He went on to say that we get paid between 30 and 50 thousand dollars for the ampututation!

Here is the problem with the whole we can save with "preventative care" debate. First, all of us are eventually going to get sick and need care. Secondly, how many of us are actually accountable enough to go and get our preventive care stuff done? United Healthcare has already figured this out. When they sell health insurance, they are sure to tell people that their preventative health checkups are covered. It is a great selling point becuase only 17% of patients that have this coverage actually go and get a single check up! People go to the doctor when they are sick, they dont like to go when they aren't. So, are we going to force them? If so how? (By the way, is not going to your preventive care checkups a pre-existing problem?)

While all this is being figured out, what should I do with the hypertensive, chain smoking, sedentary diabetic who comes in with a dead foot? One thing for sure, I wont be getting between 30 and 50 thousand dollars!

Thursday, September 3, 2009

Blue Falcon

(POTUS' unofficial Secret Service and military Call sign) Rumor has it, he accidentally overheard it ant though it meant the old cartoon superhero and his dog! (So much for a President who has never served in the Military)
I think this whole health care debate would be more entertaining to watch if it wasn't so scary. I guess the scariest thing is the rush to get something done just to take credit for something regardless of the outcome. On top of it, to then blame others for why it is not happening.
We then have ACORN and others calling us who oppose the present healthcare bills "disruptors and organized mobs"
I guesss we should call ACORN, and the other minions the Blue Falcon's Army.