Throckmorton's other signs

Bolus of Common Sense

noreply@blogger.com (Throckmorton) — Thu, 18 Apr 2013 19:28:00 +0000

We had a patient that was aspirating. The concern was whether or not it was tube feeds. Before we would add some food coloring to the tube feeds and then see what color the mucus was that the patient coughed up. Now we cant because somebody wrote a paper that it might cause a reducing agent problem. I tried to explain to the nutritionists that we were just going to use the same stuff that was in the cupcakes in the cafeteria but they wouldn't hear of it. All they said was the potential danger of the dye. In my own retaliatory manner I flooded them with case reports where tube feeding was accidentally run into central lines because it is the same color as the lipids in the TPN. They didn't think it was funny. I solved the problem by putting Gator Aid in the tube feed and sure enough he was aspirating!

This led me to wonder. We are always trying to be sure the wrong medication is not given to the wrong patient. Why don't we color the medications so that even when they are in the syringe of the bag we know that something is wrong. After all, patients take pills that are different colors. Make morphine blue, decadron yellow, ancef green and so on. That way when you walk into the room you know hey these are the meds he is on. Oh, never mind, that makes common sense.

Hand Caught in the Cookie Jar

noreply@blogger.com (Throckmorton) — Fri, 22 Mar 2013 03:54:00 +0000

We set a new record last month in the medical center. Six times maintenance had to be called to cut the top off a sharps box to free the hand of someone who was trying to get the used syringes for the last drops of the narcotics contained within them. They were all "family members" or "visitors". Two claimed it was an accident despite the fact that the patient was on seizure precautions and they were on camera for the whole thing. We also have had over 12 sharps boxes go missing.

Hour-glass sign

noreply@blogger.com (Throckmorton) — Wed, 13 Feb 2013 14:45:00 +0000

Technology is amazing. Before, I would have to roam the halls of the hospital to try and find the chart of my patient. It might be in the rack, with the ward clerk, back with the case manager or left in radiology. I probably spent several hours a week not to mention walked miles to find those darned things. Now, I just have to find a computer, log in and sit there for hours looking at the little hour-glass sign while the computer locks up, stalls and then blue screens itself into oblivion. Technology is awesome, it lets me at least sit down?

White Lie Pneumonia

noreply@blogger.com (Throckmorton) — Sun, 13 Jan 2013 18:23:00 +0000

I know that often people will tell little white lies because they want to tell you what they think you want to hear. We see it all the time. "Sir, do you use any street drugs or pain pills?" "Oh, heavens no!" We run the tox screen and it is pan positive. "Do you use alcohol?" "No." DTs on the way. I try to get people to be honest with me and try to explain that we are asking these questions so we can better help them. It still doesn't work. "Sir, did you have anything to eat or drink after midnight?", "No". The bronch after the aspiration that occured during induction for the elective surgery sucked out what appeared to be bread, egg and either sausage or ham. Talking with the family, they all hit Hardees on the way to the hospital. The patient thought a couple of biscuits wouldn't hurt.

Macular degeneration (cant see the disc)

noreply@blogger.com (Throckmorton) — Sun, 13 Jan 2013 18:10:00 +0000

We see patients from all over several states. No matter how hard we ask, most of them forget to bring their xrays. They will bring the report but not the actual films. Our schedulers call them and specifically ask them to go to where they had their xrays and have them put the images on a disc and bring it with them to their appointment. When they don't have their xrays the patients get mad because we really cant do anything until we see the films and blame us.

Curbside Contagion

noreply@blogger.com (Throckmorton) — Sat, 12 Jan 2013 22:23:00 +0000

One of my partners biggest pet peeve is when she is on the OR and one of the staff comes by and asks if she can look at their throat or listen to their lungs because they think they are coming down with a cold. Of course, if they are, it is a cold and their is not much to do about it. Secondly, you will get the cold. Sure enough, someone came by and asked her, she tried not to but did not want to look bad. Despite the flu shot she got the flu. Now she is out and so are her patients.

Negative fecal matter on the slide Dr. Sherlock

noreply@blogger.com (Throckmorton) — Fri, 11 Jan 2013 16:22:00 +0000

I know that you will find it amazing, but the recent Rand study (the same people who promoted EMRs) shows that Electronic medical records did not reduce medical costs nor did they improve care.

http://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html

Drano

noreply@blogger.com (Throckmorton) — Sun, 23 Dec 2012 18:09:00 +0000

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!

noreply@blogger.com (Throckmorton) — Sat, 22 Dec 2012 23:24:00 +0000

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

noreply@blogger.com (Throckmorton) — Sat, 22 Dec 2012 23:11:00 +0000

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

noreply@blogger.com (Throckmorton) — Sun, 28 Oct 2012 01:08:00 +0000

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

noreply@blogger.com (Throckmorton) — Sun, 28 Oct 2012 00:56:00 +0000

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

noreply@blogger.com (Throckmorton) — Sun, 12 Aug 2012 17:46:00 +0000

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

noreply@blogger.com (Throckmorton) — Sat, 04 Aug 2012 19:36:00 +0000

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

noreply@blogger.com (Throckmorton) — Wed, 13 Jun 2012 22:18:00 +0000

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

noreply@blogger.com (Throckmorton) — Sat, 09 Jun 2012 23:55:00 +0000

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

noreply@blogger.com (Throckmorton) — Mon, 28 May 2012 01:01:00 +0000

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

noreply@blogger.com (Throckmorton) — Mon, 28 May 2012 00:45:00 +0000

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

noreply@blogger.com (Throckmorton) — Wed, 18 Apr 2012 16:38:00 +0000

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

noreply@blogger.com (Throckmorton) — Tue, 03 Apr 2012 00:38:00 +0000

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

noreply@blogger.com (Throckmorton) — Sat, 25 Feb 2012 14:21:00 +0000

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

noreply@blogger.com (Throckmorton) — Sat, 28 Jan 2012 13:50:00 +0000

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

noreply@blogger.com (Throckmorton) — Sat, 21 Jan 2012 20:30:00 +0000

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

noreply@blogger.com (Throckmorton) — Sat, 14 Jan 2012 15:25:00 +0000

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.

Coal in the Stocking

noreply@blogger.com (Throckmorton) — Fri, 02 Dec 2011 16:04:00 +0000

I really, really wish insurance deductibles ran on the fiscal year instead of the calendar year! It seems all too often people put off things until the holidays hoping to meet their deductible or just give up on meeting it and wanting to get things done before it starts all over again. Soon after thanksgiving, people flock to the office to get that CT or MRI or endoscopy that they have been putting off, or to have that funny pain when they eat checked. They absolutely want it done before Christmas. Sure enough, we then get to spend the holidays being BAD SANTA telling them and their family that they have some horrible ghastly cancer. Cant we just make deductibles end on April 15th so all the bad news is at the same time?