Drano

 Somethings are a pain, sometimes for the patient, sometimes for the doctor, sometimes for both. I go up to round and as usual the nurse and assistant are no where to be found.  I check the chart and the computer and of course there are no drain outputs.  I ask the patient and she says well they emptied it in the morning and it had "fingers pinched" about this much.  Since that seems to be only a little bit and it has been in too long I decide to remove it.  There are no suture removal sets anywhere because they are all locked up in the "clean supply room".  I find a nurses aid who gives me the combination to get in to the room after she tells me, that "it is not her patient'.  Once in the room, I find all the suture removal sets are locked in the "Suremed".  I step out of the room and ask the unit secretary to page overhead the nurse who is taking care of my patient.  Turns out she was in the back in a mandatory computer order entry class.  Mad, she went to the supply room and came back with the removal set and went back to her class.  The patient just looked at me and then asked, can I go home now?

Dont Ask!

Lately it seems that every patient hints that they need some pain medication even when they are been seen for something that does not cause pain.  Sometimes they get quite belligerent when their hint is ignored.  We have tried several different ways to address this.  The one that has worked the best is to have the nursing assistant who is checking them in to hint to them first not to ask for pain medication.  This way it is caught early.  Quite often, the patient just gets up and leaves.

Delta for the Worse

The year is almost over and Boy has it been a year for big changes in our practice of medicine.  We saw a huge decline in elective surgical and diagnostic procedures only to see a huge increase in the nonelective emergency procedures.  We have shortages of life saving and generic drugs.  The government is pushing to get patients out of the hospital faster and penalizing when they have to come back.  We are rated not by outcomes and lives saved but whether or not we give enough pain meds so that we get good Press Gainey scores.  The small community hospitals are closing or sending everything out.  Catholic hospitals are getting out of the healthcare business.  More children are losing their insurance.  Mental health care is nonexistent.  Doctors are jumping at the chance to opt out of Medicare and if you have Medicaid you are SOL.  Doctors offices have to use electronic records that report your personal information to the government but do nothing to improve your care except decrease your access.  When you go to the doctor, you may not even be seeing a doctor. 

Rolling the Deductable Dice

We are being over run by patients who were advised to have an elective procedure who were waiting to see if they were going to meet their deductibles.  (rolling the dice)  Now they are finding out that their deductibles and out of pocket costs are going way up next year so they want everything done between now and the end of the year.  This seems to happen every year, but this year it is magnified by the huge jump in costs.  In our area the deductibles and out of pocket costs are doubling and patients are panicking.  Welcome to Obamacare.

Kwaulity with a K

This EMR stuff is driving me nuts.  Now we have to have all these quality measures that are mandated by the government.  All of these require more work that has nothing to do with why the patient is there.  In addition we have to complete all of these "quality measures" so the patient can have them  in the huge report that we have to generate while they are there.  The sad thing is the one most important quality measure that patients ask for is "that the doctor spend more time with them answering their questions".  So, in order to provide "quality" we have to spend less time with the patient on the reason they are there so we can focus on what they don't really want.

8 Ball to the side pocket

Boy we are seeing a lot more IV drug abuse lately in addition to the meth.  When the IV drug users are having a hard time finding a vein, they start shooting into their neck right in the little pocket between the heads of the SCM.  When they hit the jugular vein, the crushed up junk goes straight into the heart where it crashes into the heart valves and the bacteria in it grows and before you know it, they have septic endocarditis sending little abcessess everywhere including their brain.  When they stick the needle in too far, they hit their carotid and get a nice little psuedoaneurysm that also gets infected and in enough time will rupture.  No matter what though, they always seen to come in to the ED at about 200am. IV antibiotics, open heart for valve replacement, carotid bypass graft, craniotomy for stealth guided abcess drainages, counselling, treatment program.  Back in 3 months to do it all again, priceless.

Scab Eaters

We have just been overrun by scab eaters.  We already had quite a few but the number seems to just have exploded.  For those who aren't in the hand sanitized trenches, meth heads get the pops which are little blister zits on their skin.  These scab over and then they pick and eat them because some of the meth is concentrated in the scab.  Our ICUs have closed circuit cameras so we can watch for emergencies and it is amazing how often we catch family members trying to syphon off some fentanyl from the IV drips, but what is worse is how many we see pick off the scabs of the comatose patient and eat them.  These scab eaters are the worse because if you didn't have the camera, you wouldn't know they are scab eaters.  You pass them in the hall and see them in the ICU waiting area where they just cant wait to go back and "be with their loved one".

Meaningful misuse

We just got informed of all the things that we have to do to satisfy the ObamaCare "meaningful use" electronic records mandate.  At every patient visit we must determine the patients body mass index and then counsel them on weight loss, diet and nutrition.  We must also inquire about domestic abuse and offer counseling and arrange resources.  We then must discuss smoking, smoking cessation and discuss medications to help smoking.  Then in the little time that is left, we can discuss the tumor that is trying to take your life, that is unless there is another "meaningful" mandate.

Circlage

I had heard a medical tall tale of newborns who were given medical names their mothers had heard.  The classic is FEMALEm(fee-mal-ee) because the baby had already been named.  There is also a little girl named Meconium and another named Placenta.

I no longer doubt these names because I have just taken care of SirClage.

Your Government Check is in the Mail

I saw a recent interview from one of our congressman who was stressing how physicians are overpaid. I couldn't help but look at the Medicaid payscale. This is what the Federal Government pays doctors to take care of you.

To admit you into the hospital and manage a severe pneumonia in a patient with diabetes and CHF an internist gets $74 and then gets $24 each additional day he or she manages your care while you are in the hospital.

When we had a problem with our furnace, the HVAC man got $75 to come to the house, $65/hr after that plus parts and labor.

Oh, the Federal Governement pays attorneys at a rate of $200/hr.

Access Denied

I hear the term "lack of access to medical" tossed around by government officials and other who are trying to define health care policy. This seems hard for me to comprehend seeing what I do in the Emergency Departments. In the Emergency department we do see alot of things that have become serious but much of it is because the patient did not seek attention sooner. The reason they did not seek attention sooner is listed in surveys that the government likes to cite as "no access". In fact, there is access, it is just that people do not want to take the time to go to a physician much less pay for it. There is "access", it is everywhere. To get to the ED patients have to drive past numerous walk in clinics which are at Walgreen's, Caremarks, CVS as well as medical offices. The problem is that they will pay for the cell phones, chromed out rims, expensive tennis shoes and premium pay channels on their cable but they wont pay to go see a medical provider. The truly destitute patients have Medicaid which even covers their expenses and these clinics take Medicaid yet they still wont go. It is not an "access problem" it is a volition problem. People don't want to go to the doctor much less pay for it. I cant tell you how many dental abscess problems come into the ED and the classic response was I cant afford to go to a dentist, yet the patient has Bling all over his teeth. No matter what the government does and no matter what they want to call it, a group of people are going to go to the Emergency Department because they will be seen and treated and not have to pay.

Reverse Missionary Position

When we went to Guatemala in the past we would bring crates of medications because we couldn't get them there. Now, thanks to the FDA and CMS and Obamas war on "evil drug corporations" we have daily email alerts of what medications are in short supply or back order at all the medical centers our group covers. Important things like amirodorone and lidocaine drips for your heart attack, phenergan, reglan and zofran for nausea, narcan, ativan, fentynl and propofol. Pretty much everything used for anesthesia. The good thing is that we can get all of these in Guatamala! So now, instead of medical missionary teams bringing life saving medications to Guatamala, we are bringing them back!

Bariatric toilets

I hate board meetings but every now and then there is something in one that makes you wonder. The medical center has been having two new problems. The first is that the toilets are only rated to 450 pounds. Apparently, this is not enough as many are breaking due to patients exceeding the load carrying ability. The second is that a family member of a patient who is over 500 pounds not only broke the toilet but got his leg stuck between the remaining porcelain and the wall. He of course has lawyered up and filed an intent to sue. So, at the board meeting we have to find a way to rebuild all the toilets in the center not to mention find a way to cut somewhere to pay for them. In my usual not helpful way I asked just how they were going to identify which toilets were up to the task. After many suggestions and interesting door micrograms the medical center attorneys said we should just call them bariatric toilets.

Buffet patients

One of the issues that we have to constantly deal with are buffet patients. When a patient is referred to us it is for a particular reason. The referring doctor sends the related studies and labs and our staff also sends for anything else that may be needed. Time is then alloted in the schedule for that problem. It is like someone ordering a cheeseburger over the phone. You know what you need to make it and about how long it will take to cook. Then comes in the buffet patient. They not only want to discuss and be seen for what they were referred for but also ten other things. They also ask questions like Aunt Bessie has a bump on her head, what is that. You try to be understanding but also know that there are now other patients who are mad because you are running late. The office staff is mad because they are having to call all around to track down stuff that I'd unrelated to why the patient is scheduled. One of our docs starters telling buffet patients that he would address the reason they were referred and that their other concerns are just as important and would schedule another visit for those. Ofcourse he got called uncaring and inconsiderate all over the internet and patients told the referring docs not to send people to him.

DE-access

We are six months into our wonderful electronic records system. It was touted to help increase our efficiency and to allow ease of patient care. The government even touted it as something that increases access to healthy care as it became so much more efficient.

Here is what we have found so far. It has decreased the numbers patients that can be see in a clinic by 30%. Even with that reduction, the clinic runs an extra hour and half longer. The actual time of patient contact, defined as listening, examining, and answering questions has been decreased by 50%.. We have had to hire 2 new assistants for every three doctors. We are told that it would improve our coding and because of this it would be cost neutral. As of today, it has decreased productivity and only added to overhead for a cost to the practice of 112k per physician.

9% of our staff have quit. Our practice is between 9 and 14% indigent care and 20% Medicaid. We are the only ones in the area that will see Medicaid patients. We have had to cut back so much we just don't have the time to see the amount of patients we did before, much less the ability to provide for those like Medicaid that cost more than we are paid.

On the good side, we are fairing far better than most of the other practices in the area. The biggest primary care group with over 500 docs is on their third system and having more problems than we are. The bad side, if you were counting on Obama-Care you are.. You are de-accessed to the healthcare system.

The TEMPLEt OF DOOM

I hate making people wait and I know they hate waiting for the doctor and no matter what we do we always run late. We have looked at every possible appointment template and no matter what it always seems to fail. It is especially worse this time of year when everyone has to update their insurance and or Medicare info. The first appointment is at 830, we try to make that a follow up, but of course they come to the office at 830, have to update all the information which takes 20 minutes and then it has to be entered into the computer so they dont even go back until after 900. You then go to see them for what was scheduled as a brief check up of the problem that you were consulted to take care of only to have them want you to check and look at something unrelated. Meanwhile the other patients are arriving and by some type of space-time wormhole, all arrive about the same time regardless of their actual appointment time. Now the waiting room is full, everybody is mad and doesnt want to wait. In comes someone who has an appointment tomorrow and wants to see if they can be worked in. Whne you finally get to see the patients, after you see them for what the appointment was for, they say " oh, by the way, I have this stange pain down my left arm now and then, but its worse when I go up stairs!"

Comes with the Job

There are many jobs where you can avoid certain circumstances or push the hard part off onto someone else. Many days, I wish I had one of those jobs. Instead, I have to be the one who walks into the waiting room and bring the parents into the consultation room to tell them that the frozen section shows the worst tumor possible and that it is rapidly fatal. You go into surgery for what seems like a routine thing, only to find out it is anything but. They were not expecting this kind of news, neither was I. You want to save them the grief, hide from the information, hope someone else has to bring the bad news, but you cant. It comes with the Job.