Throckmorton's other signs

DE-access

2012-01-28T05:50:00.000-08:00

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

2012-01-21T12:30:00.000-08:00

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

2012-01-14T07:25:00.000-08:00

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

2011-12-02T08:04:00.000-08:00

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?

The Otis Effect

2011-11-30T10:52:00.000-08:00

We had to cancel our study of the Otis effect early because the data reached such a statistical preponderance so early. We found the following things to be true. The elevator that is the farthest from you will always be the one to open the doors. the time that the doors are open is exactly 2 seconds less than the time it takes to get to the elevator. This is especially true in the middle of the night when there is not anyone else on the elevators. When you get in the elevator and have to be somewhere in a hurry, all the floor buttons between you and your destination will be pressed. This effect is enhanced when your destination is the parking lot to go home. If your arms are full, however, the only button not pressed will be the one that you need pressed. Further, when you ask for help, someone will press the wrong button. Flatulence is immune to the ventilation effect of any elevator fan. Lastly, the person who wants to get off first will always be the one farthest back.

Bobcat

2011-11-23T06:00:00.000-08:00

My back is killing me. Sometimes it doesnt matter how many people you have to move a patient, especially when they have all their monitors and drips. Just trying to push a wieghted down ICU bed is a struggle. I was at the local lumber yard and saw someone moving a bunch of heavy duty carts. He pulled them along with a bobcat, put them where he needed them and then filled them with the bucket. It was awesome. I wonder if you can get a Bobcat into the hospital. I was thinking about a fork lift as well but with a Bobcat you load and move all that other stuff. Better yet, what if hospital beds where made by Bobcat? Each bed would be like an industrial hover-round with a winch, scoop bucket and a hydrolic lift system that you turn around real quick and easily. Press a lever and you could load and unload. When the pateints are alert they could drive themselves around.

Jelco, I Miss you!

2011-11-19T08:24:00.000-08:00

Yet another JACHO inspection is coming. Someone found my stash of Jelco's. Over the years I have learned to put these into about any vein, use them artlines and even drain abscesses. As part of a "safety program" the medical center has been replacing them with these crazy expensive things that you have to push a button or slide a snap or do something else other than just put in the IV. Worse, you then have to unscrew the darned things while the blood drips on the floor tyring to insert the IV line. I guess to improve "safety" we have to stick the patient more times and use these impractical things.

I have heard we can get some on the black market. With the drug shortages maybe I can swap some anectine for a case of 18Gs.

Flame Out!

2011-11-19T05:00:00.000-08:00

Back in the good old days, the internists, pediatricians and family medicine docs woould come to the hospital and round or even have their office next to or attached to a hospital. The doctors lounge was a place to grab a cup of coffee and run into each other to discuss cases and keep peresonal contact to see if that other doc was someone you wanted touching your patients. Now there are hospitalists. The referring docs dont want to step foot in the hospital becuase they will be forced to sit on committee after endless JACHO/CMS committee, not to mention fight yet another computer system. So, they dont even apply for hospital privaledges anymore. To keep in contact and to help build good referral relationships, we periodically go out to their offices and say hello. Last week I went to a group of awesome internists. As we were sitting down over coffee, one of them said that they were closing their practice at the end of the year. I asked him why, and said it bluntsly, he and his partners are Bingo on the fuel to practice and they were having a flame out. He said that they all find that they have loss of autonomy, loss of control of their practice conditions and their time is being more and more wasted due to all the administraction and paperwork crap. He said, in fact they were going to shut down last year but with the stock market tanking they were hanging on to see what wass going to happen. They figure it isnt going to get better so its better to just fold up. I left their office dejected, and went to the next one. Their practice is breaking up, 2 of the three are calling it quits. I wonder how much of this is happening accross the country!

What you need to know and why you need to know it

2011-11-16T19:17:00.000-08:00

Medical records used to be a helpful tool to communicate to others what was going on with a patient and how to help pass on their care. The same was true when we signed patients out to each other. A mantra that we used was to be sure we told each other what they needed to know about each patient and just as importantly why they needed to know it. What was different about that patient was immediately passed on. Ms. So and so had a colostomy after a perfed tic, she is stable but she has been on steroids! Nuff said, you knew what to watch for and where to go when things went bad. Her medical records had the pertinent positives and pertinent history. You could pick up the chart, know what was going on and get down to business. Now it is just the opposite. We will have a patient sent in from somewhere. With them will be their records. A multitude of pages that list negatives like "No family history of travel outside of North America. Page after page. You have to sit there and play "Where's Waldo" to catch a glimpse of what is going on with them and pray you find the needle in the haystack. Of course it is all computer generated so you know that someone just clicked on a template so all that is written is BS anyway to comply with some CMS thing and to have "it documented in case of litigation". Its bad enough that it was happening in the paperwork but now it is creeping into direct communication about patients. One of the residents was seeing a patient in the ED and called me to run the case. They started with all the things the patient didn't have. I cut them off and said, "What do I need to know, and why do I need to know it?" There was a pause, then more of the BS about fibro and pain scales. I finally said, "Do they need to go to the OR?" A feeble, yes was the reply. Then I asked "why do they need to go to the OR?". Severe abdominal and back pain with free air and dependent fluid on scan was the answer. "Ok, then. What else is important that I need to know?". Crit is 30, they are probably septic and have afib with a recent stent and an EF of 30%. Crisp, clear, concise. Time for a Bard-Parker Scan!

Gremlins in the wiring

2011-11-09T10:57:00.001-08:00

I just saw that the company that makes most of the surgical robots is being sued when one of the robots stopped working and the surgeon had to convert to an open case. First, I was surprised that this was a lawsuit because it is commonplace to have consent to convert to open if necessary but anyway, the suit is claiming damages because the robot broke. Like many surgical tools, the robots are designed to shut down before anything bad can happen, apparently they are supposed to be indestructible and never fail. I hate to say it, but stuff breaks. Sometimes it is the new stuff, sometimes it is the old. I have had a harmonic generator basically melt down, microscope bulbs blow, drills chew their bearings out, tourniquets explode, anesthesia machines fault out, lasers just become possessed. You don't want to know about what the perfusionists have to deal with. The point is, things break, Gremlins get into the wiring. This is the risk of surgery. That is why in addition to using all the high tech stuff, we learn to use our hands, scalpels and silk ties.

Net Loss

2011-11-09T05:22:00.001-08:00

Had to go to one of those dreaded third quarter status meetings of the medical center. Here is the breakdown. Patient volume, up. Reimbursement down. Overall costs up. Termination of 54 nurses (rns/lpns). Hiring of 71 "data management specialists". (they make more than the nurses do!)

So, in order to take better care of patients, we have had to fire those that take care of patients and then hire more people to take care of the computers. On the brighter side, we have more people to take care of who cant pay with less people to do it.

The Elephant in the Room

2011-10-31T16:37:00.001-07:00

In an effort to decrease the widespread shortage of medications, the President today ordered the FDA and the CDC to increase the things that he ordered them to do that caused the problem in the first place. Here are some of the generic, life saving medications that are in short supply due to the mandate that all older drugs go through millions of dollars of testing that new drugs go through and as a result, no one can affort to make them: fentynl, succinyl choline, etomidate, propofol, decadron, and phenergan. Before you need that life saving surgery, better call ahead and reserve some of these meds!

Is there anyone else who would like me to do their Job?

2011-10-29T05:19:00.000-07:00

We just got word that two of the biggest pharmaceutical chains as well as the national organization of pharmacists will no longer fill any prescription that does not have the quantity on it. The reason, they dont want to be responsible for having to figure out the quantity and therefore be responsible for any errors. This is on top of the fact that almost none of them will do any coumpounding. Where this is an issue is that many medications come in different doses and forms. These very big time in price. A classic is prednisone. 5 mg tabs are the same price as 10 mg tabs. So a patient can ask the pharmacist for the 10s and take 1/2 and save 50 %. Of course, the pharmacists does not ever want to substitute a suspension for the tablet because they have to do math. The governement wants us to eprescribe so they can keep track of all the scripts and your personal information. Part of this is that the script goes straight to the pharmacy instead of the patient. The result, the patient cant call around to see who has the best price! In our area, some of the smaller non chain pharmacies beat the others by a substantial amount. This is a big deal for those in the donut hole! I guess pharmacists just want us to be sure we send electronic scripts so they can charge the most, not have to be responsibe, while the government wants us to be their stool pigeons and rat out our pateints.

Un-Meaningful Use

2011-10-29T05:06:00.001-07:00

I think I almost have my computer fixed. I threw it accross the floor doing the G+D<<< Electronic Medical Records. These record systems are all build backwards and are geared towards what the government wants and not what is best for and how to take care of patients. My favorite is that they automatically report to the government the patient's use of tobacco and their body mass index! That is just the tip of the iceberg. They also record other demographic information and send it as well, such as race, sex, etc. Medical charting which at one time was used to help you take care of the patient, is now something that is done to the detriment of the patient. The patient comes in and you do your best to take care of them and then generate a computer driven bundle of initelligible drivel that no one can read, much less understand why the patient is there, thats only purpose is to comply with government mandates and by way of such what the insurance must have.

Next time you go to your doctor for that rash, just think, your BMI is being sent to the FEDs!

The Seven (deadly sins) Entitlements

2011-10-16T06:38:00.000-07:00

It slowed down a little bit last night in the ED, at least in terms of the "real Emergencies". There was still the late night cohort of the STDS, low back pain, you know, the usual. At the window was a man in his early thirties screeming at the triage nurse that he was disabled and how dare those others go back before him. I dont know why but somehow all the protestors who are in Wall Street popped into my mind. This guy is screaming that he deserves and is entitled to things because of his (deadly sins). He is envious of other going before him, he is drunk and morbidly obese, he is definately full of wrath, turns out he had a STD. Watching the Wall Street protestors, it seems almost the same thing. They are full of wrath, they dont want to work for things, rather they want it given to them, their gluttony is that they all have laptops and iphones, they want it all!, they are envious of those who have achieved, their pride is that they believe that they are entitled to what they lust after.

Locutus of Borg

2011-10-14T08:38:00.000-07:00

Just like the others, we are being forced to be assimilated by CMS with the mandate to go to electronic medical records. I have named ours Loki after the norse god of discord and mischief because it has pretty much destroyed our practice and ability to practice medicine. With out embelleshment, so far the EMR has decreased our productivity by 45%, doubled patient wait times and cost over 92K/physician to implement. Worse, it is still not running correctly. The touted improvement in the ability to take care of patients is not there, nor is improved office efficiency. All it seems to be able to do is create thrirty page reports to comply with the Federal Governments "Meaningful Use" demand.

I though we were the only ones who felt this way but then I started the whole conversation in the lounge at the hospital. There was not one doc who liked the things. On the average, they all have seen the same thing. Thank you Fed Gvt.

The Go To Light

2011-10-11T11:44:00.000-07:00

I was called in to see a patient in the middle of the night. As I was checking on them a code was called on the floor I was on. With great concern I poked my head out of the room hoping to see someone else in a white coat looking like they knew what they were doing going to the room where the code was happening. No such luck! I went over and started doing the doctor thing. Airway, tube in, pump chest, push drugs, pump, pump. In the middle of it all, it was pretty dark in the room. Someone recognized that fact and hit all the switches. There over the bed was an exam light that was stronger than a landing light of a 747, I mean it was blinding. Soon as it turned on we all had to squint. Someone in the back said, "dont go to the light"! We got the patient back, PEs suck! I couldnt help wonder how many of those "I saw a white light" stories where those darn exam lights.

Phone Solicitors

2011-10-09T15:51:00.000-07:00

One of the hardest things about being on call, is all of the phone calls. Our answering service does a great job telling patients that we can not diagnose over the phone or call in prescriptions after hours. It also tells patients that if it is an emergency they are to go to the nearest ER. Lastly it tells then that we are on call only for acute post-operative problems. So, what happens? They lie to the service and we get called. Many are drug seekers, many hope to call when the office is closed so they wont have to come in.

Here are some of the latest. A patient called stating that he had surgery and one of the doctors was supposed to call in an antibiotic and that he had just called the pharmacy twice and it had not been called in. I asked what kind of surgery he had and it wasn't the kind that doctor even did. I then asked for the pharmacy number and he said he didn't know it and would have to look it up. When I reminded him that he said "he just called it twice" he hung up.

Another person called and said that they had surgery two years ago and now they were having a bad headache, could we call in some percocet?

Three were calls from people who thought they were getting a cold, could we call in an antibiotic. (two of these were after midnight!)

I had two calls last night from people who wanted to set up an appointment at some time during the month.

I know I have talked about this before, but I just had to vent.

Rule number two

2011-10-07T17:35:00.000-07:00

I was doing rounds and right next to me one of the critical care attendings was also doing rounds with his posse of fellows, residents and medical students. He is a very brilliant, quite person who I had never heard crack a joke or even change his expression. A young intern was explaining that the patient came in with sudden mental status changes and fever. They had done a spinal tap which was bloody but did have some white cells. The attending asked what the next tap showed, the intern explained that they only did the one. The attending looked right at him and said, always remember "rule number two!". I cracked up. He looked right at me and grinned, I explained that I had better run, "you know, rule number one!" Only the medical students seemed to know what we were talking about when one said that he knew where there were some twinkies!

Cyber Staph

2011-10-07T17:27:00.000-07:00

I knew it was going to happen sooner of later, but I was surprised how fast it happened. Ive heard about computer viruses but now we have computer bacteria. We had an uptick in the number of nosocomial infections on the first floor to have computer order entry mandated. Most of these were staph. After an exhaustive search we found the source. It was of course the computer keyboards that were used to enter all the orders. It appears that once the keyboard is contaminated it is rapidly spread because people have to keep going to computers to do anything and before you know it, the staph is spread everywhere. Worse, there is no way to clean and sterilize the keyboards. The touch screens were worse because they seem to keep a static charge that attracts all the floating dust and bacteria to the screens! One of our administrators suggested that all computers becovered in one of those keyboard plastic things, but when I mentioned the tough screens he blew me off. I saw him later sneeze and cover his computer with mist!

Kobayashi Maru

2011-09-24T14:19:00.000-07:00

We are now in the third month of our government mandated electronic medical records system. It is amazing, not only does it require more staff, it also allows us to see half as many patients in twice as much time! On top of it all, patients complain that the computer is being takencare of instead of them. For the patients who are really lucky, it Eprescribes their prescriptions to one place so they cant shop around for a cheaper price. On a side note, we have just learned to break into the system so we can at least bypass some of the government mandated stuff to at least try to take care of some patients.

Butt sweat

2011-09-23T19:10:00.001-07:00

Every now and then there is something that happens that no matter how hard you try to keep your composure, its all over. Today was one of those times. I was doing a history on an older patient who was being admitted. His family member was trying to recall all his medical problems when one of the things that was going on was "something that sounded like butt sweat". I couldnt figure it out until at last it made sense. The patient was having problems eating. Then I got it "AS-piration!"

Surgery cant cure phantom symptoms

2011-09-11T05:56:00.001-07:00

Every now and then there is a patient that makes you just sit back and know that it is going to be a hard case. Not because it is technically difficult, but that the patient will be difficult. What I mean is, there are some who make up symptoms to be put into the hospital for the attention that it gets them. This is far more than the fibro patients. These patient complain of everything, but on careful questioning their symptoms wander all over and they cant quantify or localize any specific complaints. Unfortunately, sooner or later, someone will do a diagnostic study for one of the most rare conditions that exist. In the study, something incidental will show up. The patient then focuses on that and we are off to the races. Well, we had a patient like this show up in the ER. They were admitted and started their whole history. When the resident called me, the first thing I said was call every medical center in a four hour radius and get all her records and charts. Sure enough, the patient had been in every one and had every test known to medicine. At each hospital was a psyche consult that showed the patient was not right. This patient had years ago complained of vague abdominal pain. Unfortunately, someone went and did a laporoscopy. So every time she comes into the hospital, someone else decided that since nothing is showing up she needs another laporoscopy or open exploration to look for adhesions. As a result, we are off to the races. It is going to be a long call week.

Anton's Syndrome

2011-07-30T14:09:00.000-07:00

In true wisdom the administration decided on a computer order entry system and then mandated that the whole center go live with it last Saturday. They turned their blind eyes towards all the problems that were pointed out in the system and did not bother to discuss it with the physicians. It lasted 71 hours. Even with all their manadated training and PR the system crashed the whole medical center and increased medical errors 10 fold. There had to be an emergency halt placed on using the system and an immediate reversal to go back to the old charts. Still allowing their Anton's Syndrome to override all logic, the administration now states that it will be back on line once the small bigs are fixed. The biggest medical errors were of course, people paying attention to the computer instead of the patient!

"I love the smell of Play Doh in the morning!"

2011-07-30T14:01:00.001-07:00

We had a JACHO inspection of the Childrens Hospital last week so all the things that really matter to the kids were hidden. Of course with JACHO you cant have toys for the kids to play with because they might have germs or be racially/socially incorrect. Crayons are right out becuase they are a choking hazzard. Now that JACHO is gone, we can bring out the one thing that helps every child in pre-op as well as their parents. Play Doh! Sure it is against JACHO, but you can hand it to any child and they immediately start playing. For patents, the mere smell brings them back to their own good childhood memories. It is a sorry state of affairs when we have to smuggle Play Doh into the hospital!

Digital Neglect

2011-07-03T07:02:00.000-07:00

I'm having a bit more time to write as I wait for meds to come up from the pharmacy. Before we could call down and they would tube them up. Took about 5 minutes. Now it has to be entered into the computer where it vanishes and you wait and wait and wait. You then call down to the pharmacy where they reply that they have to log in to see if it has made to them. If it has, they have to do all kinds of other stuff on the computer before they can go get it, mix it and finally send it up. Takes about an hour. Isnt efficiency great! Anyway, as you can tell one of my pet peeves is taking care of the paperwork instead of the comouter. I have been collecting incidents where this has happened but some of my favorites are when the family memebers take matters in their own hands becasue the person who is supposed to be taking care of their loved one is too busy on the computer to come and do their job. the latest is when a patient had accidentally disconnected his feeding pump from his NG feeding tube. I happened to come in and saw the wife put it back on, reset the pump and sit back down. I was impressed. She saw my look and said, that she knew how to change the IV bags, reset the IV pump and zero the lumbar drain. I asked if she was a nurse. She said no, she had to learn becuase the nurse was too busy to come in and fix these things. She added, "God help those pateints who dont have anyone with them!"

Scavenger Hunt

2011-07-03T06:50:00.000-07:00

We do our best to share the pain of who takes call during the holidays. This year it is my turn to take call during the great medical center wide scavenger hunt called the first week in July. This is when all the new interns start. They are doing their best to find their way around while learning to take care of patients. Of course, the new "patient centered focus" means that instead of actually learing to take care of patients they are learning how to navigate their way through the hospitals new Computerized Order Entery system that was also started this first week of July. (note to self, dont get sick the first week of July). Where we used to have interns lost trying to find interventional radiology and the microlab, they are now lost in cyberspace trying to figure out why insulin is listed in the computer under "adult" instead of "insulin"! Before, interns and residents all had Washington Manuals in their pockets so they had a quick reference on what to do when the patient s/p xlap for dead bowel went into vtach. Now their pockets are full of notes on how do you log in and make your way through all the HIPPA screens to find out if the patient already had been given his K. I was called in to consult on a gentleman and when I sat down and talked with him, he said "I hope that d*** computer is doing better because I sure aint!"

CPOE DOA

2011-06-27T19:00:00.000-07:00

I just had the opportunity to see what happens when you mix hospital administrators with computer geeks and accountants. You get computer order entry. This is basically where instead of writing orders in the chart, you have to find a computer and then enter them. This seemes like a great idea to the people above who have never been in the ED, OR or a hospital unit. It kind of goes like this. You go up to see your patient. Of course, to find out what has happened and their labs, you have to log into a computer. You then walk in to see the pateint, do your exam and then have to relog into the computer to enter what orders you want as well as to review what other orders others have written. Of course, you have to do this to every patient. Wait a minute, the nurse and the CNA as well as speech, nutrition and everyone else has to enter everything into the computer as well. What, their isnt enough computers? So now you have to wait to find a computer. Since it logs you out because of HIPPA, you just print everything out so at least you have some of the information. You then write your orders down on scrap paper until you can find a computer to enter them. This is what administrators,accountants and computer geeks call efficiency. Yet another great example paperwork (now computerwork) over pateint care.

Foxhole Faith

2011-06-25T21:05:00.001-07:00

Several years ago I took care of a college professor. He had sent me a letter saying that he did not like my manner. Spefically, he did not like that I said God Bless You at the end of each encounter. He had written taht he did not believe in God and that may saying that was offensive to him and therefore wanted all his records and was finding a new physician who was in tune with his beliefs and was not forcing their faith upon him. Anyway, he showed up in the office this week with a stage 4 tumor and asked me to be his surgeon to remove it. I still said God Bless You, he replied, I need it.

Maimonideen Moment

2011-06-25T20:48:00.000-07:00

We had a dinner to celebrate the retirement of a great doctor tonight. Like many doctors, he really wasnt retiring just scaling back to one day a week. Throughout his career, he never asked if people could pay, infact, many times he never charged. He never turned anyone away. As we spoke of our esteem for him, someone said something that just struck me. It summed up what we are and who we are. To paraphrase: " As physicians, we see all regardless of their race, income, predjudice, social class. Those we see entrust and share with us their souls in the form of their fears, aspirations and worries. We see all as equals in gods eyes and we never see a patient anything but a fellow creature in pain. We are entrusted with the souls of our patients, to provide comfort for their pain and to watch over them. This is our calling, a calling that exists forever and can not be recended, it can only be passed on with greater understanding of its dimentions."

Cooties Jump both ways

2011-06-24T20:14:00.000-07:00

When I go to examine a patient, I always put on a pair of those purple gloves that I despise. Today, I went to see a patient and said hello and put on the gloves when the patient said that he did not want to be touched because Drs carry all kinds of germs and spread them from patient to patient. I paused and thought about it for a second. I had to see this gentleman because he had a huge abscess that he got from drug abuse. He was unkempt and had a rash all over that looked like a cross between meth skin and scabies. I dont think he had bathed in a while as the odor in the room reminded me of a gym bag that had been left in the trunk of a car in a hot day covered with all the old laundry that a football team could muster. Politely, I accommodated his wishes but I have to admit I was the one who was more worried of catching something.

Air Getting to Cancer

2011-06-17T20:20:00.000-07:00

Three times today I had to explain the same thing. In each case, a patient had a lymph node that was suspicious and I was asked to remove it for a biopsy. In each case, the pateint at first refused because he/she had heard that once you get air to those, cancer goes everywhere. I try to explain that cancer does not behave that way and that in those cases that they heard that about the cancer was everywhere and the biospy just proved it. It is hard because I dont want them to think that the cancer is everywhere becuase we hope that it is just in the single lymph node but you can never tell. It always seems that no matter what, if the node is positive, the pateint will think that you spread the cancer because you got air to it.

EPA Job creation

2011-06-17T20:08:00.000-07:00

I have a large group of patients that I take care of to the best of my ability who have lost their jobs and insurance. Most have had cancer, some chronic conditions. I had one come in today. He was both happy and sad because he now had a great paying job and good insurance but it was temporary. He is an Iron worker. He explained that suddenly he and his collegues have more work than they know what to do with. They are taking apart factories that had shut down hoping for the economy to improve. Apparently there is some new EPA regualtions that will make it very costly in the future to dismantle factories so any factory that thinks it may not be able to reopen in the future is in a rush to tear it down. In my patients case it has created jobs cutting up the steel and breaking up the boilers into scrap that is then shipped to China. Of course, all the jobs that the factory had were lost, and now the whole factory is lost and can not be re-opened, temporary jobs were created because the EPA regs, but once the factory is gone, so will the jobs.

JACHO/HIPPA free Zone

2011-06-10T17:30:00.000-07:00

It was so refreshing. I saw over 400 patients and did not have to worry about JACHO or HIPPA. Of course it was on a medical mission trip to Guatemala. We saw and treated patients. We saw vitamin defieciency causing blindness, parasites killing children, simple infections devastating families and treated them all. Some we treated in mud huts, others on the floor of simple churches. The pateints were thankful. I wonder what JACHO would say about the hospital that was made of mud? Would we have to get HIPPA waivers for all those who formed a circle and prayed over our patients? I think JACHO needs to go on mission trips.

Throwing in the Towel "Time out Towel" to be exact

2011-05-25T20:22:00.000-07:00

Ok, I understand the need to do a Time Out when starting a surgical case, but what happened today just blew me away. There in the room was a Registered Time Out Safety Towel! It is just an Orange towel that says time out. Of course it is trademarked and no doubt created and owned by someone who works with JACHO because these just showed up before our latest JACHO inspection. I had to ask how much these cost. Well, since they are in the OR they must be sterile and have a thread count that makes sure that they wont leave lint on the instruments. Of course, they are disposable. So, guess what. A box of 24 individually wrapped, sterile Time Out (r) safety towls is $112.00. So, instead of just having the time out, we know have to have the JACHO approved and probably wholly owned useless towel that just ads even more cost to the health care system. I hate to admit, I took the towel and wadded it up and threw it as hard as I could at the hamper only to be told that they couldn't be reused!

Gamer's

2011-05-21T17:04:00.001-07:00

I have been noticing that alot of the patients that we see who are on Medicare and Social Security Disability are rather young. Many are under 45 years old. Being rather a cynic personally, I asked the front desk to keep track this week if they could how many patients I saw who were on Social Security and Medicare/Caid who met the following criteria: under 45, able to drive, talk on the telephone, and walk. The last three I included because I figure that if you can do these, there is at least some job that you can do. The answer they gave was a bit shocking to me. It was 18! I dont know if this was a high weekly number or a low weekly number. But still, 18! I am not sure what the truw dollar amount of full Social Security Disability and Medicare/Medicaid is but I can imagine both combined might be about $20,000.00. This is probably a very low ball estimate as these folks are receiving care that normally would have been covered by private insurance. Anyway, 18 time 20K is $360,000! This was in one week! No wonder Medicare and Social Security are going broke! I shouldn't have gone back up to ask the our front office staff anymore questions but I couldnt help my self. When I asked them about the number of people who met the criteria, they said "oh, yeah the Gamers". I asked why they called them that. They explained, "oh, they know how to game the system, they all are on disabilty for fibro". I said, "no, way, all of them?". They answered, "not really, two were on it for chronic fatigue". I asked why and they looked at me like I was a moron. "they have fibro and chronic fatigue because it gets you free money!" Great, we are all screwed!

Pine Box Warning

2011-05-07T19:06:00.000-07:00

I had to give a pine box warning to one of our pharmacists last night. The patient had a deep rapidly spreading infection and was allergic to penicillin and all cephalosporins. The infection appeared to be gas forming and we needed to jump on it in a hurry. He had already failed Flagyl. I wrote to get him started on 900 mg of cleocin every 8 hours asap and made arrangements to go to the OR. When the patient got to pre-op, he still had not received his cleocin. I called the pharmacy to see what was up and immediately was told that it had to be appoved by the pharmacy supervisor on call because cleocin had a black box warning. After I told them that I didnt give a ***it and that I wanted it now, I asked them what was the "lack box warning" It turns out that it can lead to C. difficile diarhea. I told them that I hope they do get diahrhea, that means that they will still be alive! Right now there is a Pine Box Warning, without it, they will be dead!

I got the cleocin and the patient did ok. Anerobic infections are no fun. Anyway the head of the pharmacy called me and apoligized for the delay. She told me that from the administratosphere and edict came out that to decrease complications that may lead to extended stays in the hospital (CMS) unfunded and possible litigation issues, they had instituted this Black Box Warning policy!

Cant you see I'm Charting

2011-04-26T17:32:00.000-07:00

One of my biggest pet peeves is when more attention is paid to the chart than to the patient. Boy, today I got peeved. I was seeing a patient in one of the units when their asymtomatic tachycardia became very symptomatic with the sudden accumulation of a large amount of blood with froth in the chest tube. At first I thought it was something even more worse than it appeared but I managed to press down on the chest and twist off the chest tube hoping the bleeding would tamponade the lung. While all this is going on I am yelling for help. After four or five yells and trying to use my foot to hit the code alarm I finally heard the nurse yell, "can somebody get that, Im charting!" The RT popped in when the vent alarms went off and helped me. Finally the nurse showed up. After the patient was taken care of, I though about what had happened. If I hadnt been there, the chart would be perfect but the patient would have been dead.

Federal Reserve Blood Bank

2011-04-22T19:24:00.000-07:00

I know it is a scary thought, but what if the Federal Reserve ran the blood banks? At present, one unit of packed red cells is 220 ccs and intended to raise the hemoglobin by one point and the hematocrit by three. To make it look like there is more blood available,the Federal Reserve would increase the number of unit bags that the blood comes in, so each new Federal Reserve Unit would be diluted and maybe only contain 110 ccs of blood and the rest of the bag would be filled with saline. Sure, there are now more units available, but now each unit only raises the hematocrit 0.5. So, in each transfusion you need twice as many units. The real amount of blood available is the same, all you did is make each "unit" less effective.

I guess it is a good thing that the Federal Reserve does not manage blood banks, too bad they manage our nations life blood.

Non-essential functions

2011-04-06T14:13:00.000-07:00

I saw on the news all these different governmental administrators explaining that a government shut down would only affect non-essential functions and that they were working on plans to operate in this way. They also said 800,000 people would be placed on furlough with the shut down. Doesn't this mean that we have 800,000 people who are government workers doing nothing important and therefore why do we have them anyway? For that matter, why do we have things in the government that are not essential anyway?

What's good for the goose killed the gander

2011-04-02T06:31:00.000-07:00

I was just sent an email from a friend. A senior National Health Service Administrator in the UK passed away from gastric cancer. It was diagnosed earlier but she had to wait 9 months before her surgery. The surgery was even done at a hospital that she was in charge off. Of course it was way to late. I then thought what if it was over here in the US? You come in to the ED with stomach pain or nausea. They will get a ct regardless of your ability to pay. If UT shows a mass the surgeon on call then has to see you as well as the gastroenterologist. Before you know it you have the egd done, biopsy read and most likely surgery and the first round of chemotherapy before you even left the hospital. Sure you may get bills but if you don't have insurance the hospital writes most of it off and the doctorsa have to suck it up.

So, who has the better system if you are the patient?

There is always more than one patient

2011-03-28T18:19:00.000-07:00

I had just finished a case and went to talk to the family. When I got back, one of the residents asked what took so long. I paused and then thought a bit and tried to explain. I told him that the person that went to the recovery room was not the only patient. While we were operating and dictating, someone is sitting in the waiting room worrying. There the clock seems to stand still. They are worried about their loved one, worse, they are helpless to do anything. Every time the phone rings, they jump. When the surgery is over, they have to face the news of what was found and what happened. Is there cancer? Are they going to be OK? What happens next? The person that had the operation is still asleep. The family and friends have to face the news wide awake. They are your patients too. Time and answers to their questions are the medicine that they need. Surgery takes as long as it takes, so does meeting with the family and friends.

Medical Ductape

2011-03-25T07:49:00.000-07:00

I think there ought to be a medical hall of fame somewhere for the people who have contributed the most to medical care but who have not had their name placed on their invention. One of the most awesome things is that Mefix tape. It is like medical duct tape. It will hold in chest tubes, NG tubes and hold pressure on wound until you can pigure out what to do. Another cool thing is that artificial snot stuff that is on the back of EKG pads. It sticks, but you can pull it off later and it is like the rubber cement you used to put on your hands and play with in grade school. I dont know who invented it but I like how you can cut the end of the tube that chest tubes come in, and then use it as a blow gun to shoot those oral care sponges on a stick. Pillow packs. These are cool, besides being a convient way to get saline to lavage a plugged ET tube, they are awesome one shot sniper squirt guns. Opsites (tegaderms) are cool too. See through self stick sterile saran wrap. I wish I would have though of it. I think there should be a special place in the Hall of Fame for the person who can come up with a way to open all the sterily packaged stuff with gloves on. I hate having to open some of that stuff with my teeth!

Air Traffic Controller Lapses

2011-03-25T04:31:00.000-07:00

I just saw on the news that the air traffic controller at Reagan National Airport fell asleep and as a result two aircraft low on fuel had to make landings. The Air Traffic controller's union in perfect form blamed the issue on staffing and not on the fact that the gut was asleep on the job. It is a good thing no one was injured. I guess unions are a good thing. If we decide that we are going to take a nap and ingnore the emergencies coming in to the ED, we are going to get in huge trouble. I guess that is why docs cant form a union, its not like we are responsible for bunches of people who could be in danger.

Ball Park Amnesty

2011-03-25T04:24:00.000-07:00

I just had the opportunity to go to a professional Spring training baseball game. On the ticket and also announced in the stadium was the statement that "Baseball is an inherently dangerous sport and baseball, bats and other objects may cause injury, the stadium, team or its employees are not responsible for any injuries that must occur." By entering, you assume all liability for any injury. So, in other words, if a highly trained professional accidentally slips and lets hits bat fly into the crowd, he is not held responsible. I kept thinking about this. Medicine is an inherently dangerous activity, perhaps we need Ball park Amnesty! If a surgeon has an accident, he is sued. Oh, wait a minute. We cant have accidents, only malpractice.

Toll Free Calls?

2011-03-05T12:53:00.001-08:00

I think the thing that takes the biggest toll on me while taking call is the constant barrage of phone calls. I understand the calls from the hospitals and the ERs and the patients who are recovering from surgery. It is the other types of calls which is the majority and the biggest pain in my side. We have an answering service that does their best to screen the calls and the phone system even says "if this is an emergency, hang up and dial 911." It doesn't make a difference, people lie to the answering service and you get calls like this. "text message: patient had surgery by Dr. (partner x) and now has severe nausea and vomiting." Of course it is 2 am. You call the patient, he is drunk. Turns out the surgery was a small office procedure 2 years ago. The patient is drunk and wants nausea medication called in because he doesn't want to still be puking in the morning. I give him the speech that we do not call in medications after hours and that we are on call for emergencies for which he calls me every name that would get my mouth washed out with soap as a kid. After he hung up and I dealt with other people calling for zpacks and antibiotics for their colds, I decided to look up the drunk guy on Google. Turns out he owns a bunch of car dealerships. I so wanted to call him back in the middle of the night and tell him that I had a headlight changed at one of his dealerships and want him to call in a new muffler for me at Autozone so I wouldn't have to have my car make so much noise in the morning.

Parachute Paper

2011-02-26T19:04:00.000-08:00

About once a year I give the medical students and residents a talk on how to read and analyse research papers. I do my best to explain that just because there is a paper that says something, it might and most likely is just BS. We go through whether the study has a proper design, statistical analysis and if its conclusions are supported by the reaseach. At the end of the talk, I always finish by saying, when push comes to shove, trust your experience and your own observations as this is the best BS test of any paper and them I give them the Parachute Paper!

Parachute use to prevent death and major trauma related to gravitation challenge: systematic review of randomized controlled trials.
BMJ 2003;327 number 7429

As an aside, I was called to give a deposition when there was a lawsuit against one of our docs. The plaintiffs attorney kept showing me papers that he got off the internet. I gave him a condensed version of my talk and gave him a copy of the paper. They dropped the case.

Environmental Crisis of non-epic proportions

2011-02-26T18:40:00.000-08:00

Warning, this may contain some actual scientific postulates.

I'm stranded in the airport. We have a plane but no crew. This leaves me with more time and very little to do to settle my ADD. So here is some of my rambling.

Somehow I got to thinking about the gulf oil spill and remembering how all the environmentalists were screaming about how bad it was and how many microbiologists were saying it was no big deal and that there were microbes in the ocean that were going to eat that stuff right up. In fact, it was adding to the microbial food chain. As it turns out the microbiologists were right. I then started to think, well perhaps oil is part of the food chain. I mean, we have bacteria that have evolved to eat oil so it is part of their food chain, that means perhaps something else eats something and excretes oil. I know that there is a bunch of research trying to use recombinant technology to get algae to excrete oil, but I got to think that there is already microbes that do it. All microbes need a metabolic fuel. Well, plant and animal tissues contain amino acids as their building blocks with some carbohydrates thrown in. Amino acids have by definition amino groups. These amino groups contain a large amount of energy which could be used to power microbes. This would allow the decomposition of bio-organic materials, producing free nitrogen and splitting off hydrogen to allow it to combine with methane moieties to create hydrocarbons. This would also explain why we have so much nitrogen in the atmosphere as it would be in circulation just as the CO2 and O2. How long do you think it will be before someone discovers a ammonia loving microbe that lives deep in the soil that eats coal and secretes oil and natural gas with free nitrogen as a byproduct? What will the anti-oil environmentalists do when they find out that oil is a natural part of the world food chain?

Non-union

2011-02-19T12:31:00.000-08:00

I was just sitting at home listening to all the talk about the Wisconsin teachers union and how many democrat politicians are all about the rights of unions and collective bargaining. I was wondering then, why is it not legal for physicians to form a union? For that matter, if we as physicians form too large of a group, the Feds force us to break up. Here is something. I am a teacher ( in a medical school). Does that mean I can join a union?

Attorney PSA

2011-02-18T18:16:00.001-08:00

As a general rule, it is not wise to stop your medication because you saw an add for an lawsuit clearing house on TV. I know its hard to believe but it probably was the plavix that was keeping your coronary arteries from clogging despite it being on 1-800-BAD-DRUG. I hope that you recover from your massive MI and have a chance to watch some of the other lawsuit seeking commercials.

I'm sorry to vent but it is getting ridiculous. We really did have a patient today who stopped their plavix because they thought it was banned after seeing a commercial on TV.

The Anti baffle with BS EMR Tab

2011-02-18T07:52:00.000-08:00

It took many meetings and a ton of phone calls but we finally have our medical centers EMR equipped with a feature that lets you actually see on the same screen what you need to take care of the patient. Better yet, it can be printed out and placed at the patients room so you can see the patient and then check everything without having to find a computer, log in and wade your way through all the sections of pure computer generated BS.

Originally, the patients chart was a way to keep track of important lab values and information that let you take care of the patient. This was its whole purpose and its most important purpose. It is now a billing, government compliance checking monster in its own right. More time is spent on the paperwork than the care. The actual stuff that you need to take care of the patient is lost in the sea of BS.

I was so happy that we were able to get it so the nurses could print off the single page review of the recent vitals, I/Os, meds and labs. Unfortunately, the medical centers attorneys are afraid that if this is left at the bedside where we used to keep the patients charts it would be both a JACHO and potential HIPPA issue so they made it so you can not print it! So here we go again, Ms. Jones is coding, someone please find a computer and log in and make their way through all the HIPPA screens and all the other BS to find out what meds she is on and what has been going on!

Obama-innovation

2011-02-05T17:31:00.000-08:00

I listened to the President talk about how he wanted to promote innovation. The problem is that he and his team have so alienated the pharmaceutical industry that many of our drugs are in short supply or no longer can be found, and here is the latest. Phizer announced that it is laying off thousands of its research and development personnel and moving its whole antibiotic research facility to China. Maybe we can use Obama-innovation and move our whole health care system to China?

(Dumbing Down)(Dumbing Down)

2011-02-01T19:31:00.000-08:00

One of the concerns that we have had in the surgeons lounge is whether the new resident work hour limits have "dumbed down" the residents education. It is hard not to think that by decreasing the work 50% that you wont decrease the experience by 50%. On top of this, is that concern that we are further dumbing down our care by replacing residents with NPs. In one of the most ironic episodes, I was in the lounge last night waiting for the patient to have an artline discussing this very thing with another doc waiting for his post op film when I got a stat consult. The patient had come in through the ED where they were seen by an ARNP who consulted pulmonology. It was another ANRP from pulmonology who came and saw the patient and then arranged for admission who then called for the stat consult. The consult was for acute shortness of breath, decreased breath sounds on left! When I got to the room, the patient was pulling a chair over to see if he could stand on it to adjust the picture on the TV. He had a slight wheeze. I asked if he was short of breathe, he answered," Oh, yeah". I asked how long had he been short of breathe, to which he answered, "ever since they removed my left lung". I thought either I am being set up or this is candid camera. I asked what brought him to the hospital this evening to which he replied that he was having some abdominal pain from his old ventral hernia. Being paranoid, I checked him over and then went to the chart. There in all the best EMR was a six page history and physical of computer generated mumbo/jumbo. No where could I find anything that mentioned his hernia or the fact that he was missing a lung. I went to call the resident who had approved the admission but he had already left and signed out to another. This resident stated that the patient was having severe SOB and pneumothorax and that surgery had been called to place a chest tube! I then tried to call the pulmonology ANRP, but they had also finished their shift and left!

Welcome to the world of "not accountable" "Shift" "Dumbed Down" medicine.

Those who cant, teach!

2011-02-01T19:24:00.000-08:00

In medical education, the apprentice principle is in high regard. That is to say, you want to get your residents out working with those in the field who are actually working. It is one thing to have lectures by researchers, but it is much better to be out in the field working with those in the trenches. This has led to the attitude that the ones who are good at the actual job are the ones doing the job. Those that suck, sit in auditoriums and teach. That little bit of Dogma got me thinking. Our President taught Constitutional law, but the law that he proposed, pushed and signed was declared unconstitutional. I guess, the principle that "those who cant, teach!" is true for attorneys as well

Squad 51, Squad 51

2011-01-30T05:02:00.000-08:00

On call, one of the hardest things to get used to is to be in the deepest of sleep and then have to wake up and immediately run in to the hospital and perform something complex at a moments notice. The littlest things help ease it though. Instead of using beepers, we now use our cell phones. Before you would get the page, roll over and see the number of the ER. There would be a groan and then you would dial it not knowing is they needed and order for Zofran or that you had to get there stat because someone was bleeding out. Each time the beeper went off, there would be that little bit of anxiety. One of the big problems it that quite often, it was enough to make it hard to get back to sleep. With our cell phones, the text message goes off and right there is what is the problem.

Now, the fun part is when the ED calls or another part in one of the medical centers, we can assign them a ring tone. The ED is the Squad 51, Squad 51 from the old TV series Emergency. The patient placement/transfer office which is where they tell you another dump is coming in from somewhere is "Incoming tactical NUKE" from the Transformers Movie. Hospital Administration is "Run Away, Run Away" from Holy Grail. Fast track, which is like a mini-ed why are you here place is a Siamese cat whining. There are a bunch more but is Sunday morning and like always we are of to the OR for something that was elective 2 months ago but is now urgent!

Push pull the Pyxis

2011-01-29T15:43:00.000-08:00

I remember when you went to round on a patient and the nurse would be right there to update you on what was going on and any of their concerns. If you had to pull a drain or chest tube, all the supplies would be right at the bedside. Not anymore. First, you cant tell who the nurse is. Most of the time the patient does know either. When you do find out who the nurse is, they are stuck somewhere entering stuff into a computer and cant seem to be made interested in anything else. When you finally track down the drain amounts and see you can pull the drain, you have to go to the locked medication/supply room. They all have these key locks, and of course you then have to track someone down to find out the code. Once you get in, all the supplies are locked into the Pyxis thing. This is like one of those big vending machines where you put your money in and coil spins and you hope what you are trying to buy drops into the chute where you can get to it. The Pyxis makes you enter a code, which of course is another step to track someone down to get, then you enter the supply that you need, and just like that bag of chips it sticks. You stand there and after a few seconds of making sure no one is looking start to push and pull the whole thing back and forth hoping that your suture removal set drops before the whole thing crushes you and puts you out of your misery. The suture removal set is all set to drop, you are eying it like a midnight secret snickers bar when all of a sudden the alarm goes off and the whole thing locks up! You then go to the ward clerk and borrow the scissors they have to cut the arm bands off the discharge patients and take the sutures out with them!

Federal Working Hours

2011-01-28T09:39:00.000-08:00

We had a big incident at the medical center where one facility who could have taken care of a patient instead chose to transfer them on to another. I had to discuss this with our regional CMS office. I went to return their call. It was 8:00am. I was told that the person I was trying to reach usually doesn't come in to about 9 or 930. Not that they were in a meeting, just that this was the time they choose to come to work. I got busy and then called at 11:30. They had left for lunch. I called at 1:30. They were not back from lunch yet. I called at 3:45. They had already left for the day. I asked to speak to the supervisor. Turns out the supervisor was the one that I had been calling for all along. I decided to call the main office. It was 4:15 their time. I got the message that their office was open 9 to 5, and that I should call back the next business day? Got to love the Feds.

Real World Lesson #2

2011-01-28T09:32:00.000-08:00

I just had a patient tell me that his generic colchicine that he takes for gout used to cost $18. It now costs $154. Turns out that the Feds have placed regulations that all old meds have to meet these new testing and other criteria. No one can afford to pay for all these new tests for the meds that have been around since the dawn of time, so guess what? The generics are either vanishing or getting more costly. Real World Lesson #2: Regulations make things cost more.

Real World Lesson 1

2011-01-28T09:28:00.000-08:00

It has been the usual week on call with lots of un insured patients coming to the er instead of stopping by a walk in clinic and paying cash. What has been unusual is that three of the first real cases were patients who had great health insurance until the 1st of January when it became so costly, their employers asked the employees to pay some of it. Of course, they didn't, so here they are now without insurance. Real World Lesson 1: Obama care costs more and results in less people with health insurance.

Bubble Belly

2011-01-21T08:53:00.000-08:00

There is a great book that you can give to pregnant ladies called "What to Expect when you are Expecting". I wish that there was a whole series for other things in life, and especially a "Dummies" version. That way, instead of having to come to the ED in the middle of the night, they could just had the book to the person and send them off. Last night, the "Dummies Book" would be "Things you shouldn't put in your PEG tube".

One of our local citizens who has severe esophageal stenosis because he drank some of his meth making chemicals by accident when he was high came in after he was found down by the police. He had severe abdominal distention. On exam, it was found he had a G-tube, so they uncapped it and it sprayed like a fire hose around the room. Somehow, he had found a way to fill his stomach with beer before it had a chance to clear the carbonation and had capped his tube. Talk about a mess. (Blood alcohol of 0.29 so no record).

Plethor-orders

2011-01-15T06:54:00.001-08:00

I got the nasty call again. It was from medical records demanding that I sign all my delinquent charts or I would use my admitting privileges. I couldn't believe my luck, I was just starting to go on call. If I could not admit patients, I couldn't take call. Or so I though. The medical records person figured out quick that I was way to happy and then told me that the privileges would be suspended after my call. Dejected, I went to do my records.

It used to be that when you did your medical records, you went into the bowels of the hospital with a big cup op coffee and charts after charts were piled in front of you will all these little sign here stickers. After you signed all the places you would toss the chart into a bin with thud that was Pavlovian kind of like the ding ding of a slot machine. Alas, this is no more.

Now you sit in front of the computer and it shows you the chart. They tempt you right away with this feature that lets you hit one button that says, sign all. Oh, it is so tempting! I couldn't do it. Instead, I went to each document that the computer pulled up. There were hundreds of them. There were things in there that I had never seen, much less agreed to or even knew about. It was like the hospital attorney had hidden every possible thing in the record to make me the fall guy if anything happened. Most of it was in what was called the physician attestation statement. There were pharmaceutical risk documents so if someone got a reaction, the hospital would not be sued, there were restraint orders that I never ordered. I found several on patients that I had never heard of much less been their doc.

I brought this up at the medical executive committee, still trying to convince them to never put me on these committees. When I showed them what happened when you hit the sign all button which all of them had, the room went quiet. There was a definite air of hostility and the flurry of Blackberry activity ceased. A sign that people were really listening. Suddenly, there was a motion to "get the GD F+++ hospital attorney down here state" that got unanimous driving finger seconds and votes. When the attorney came in, the silence was deafening. Finally, there was the standard, some of those forms are JACHO and CMS defaults with the EMR system. No one bought it. I asked who approved the forms to be in the chart. We got the lawyer talk delay, I am not sure but will research it and get back to you.

I motioned that no one sign any charts until this is resolved. Driving finger approval all the way around. Our first doctors strike is on!

Adding Levels of Ineffeciency to reduce the cost of care

2010-12-24T06:27:00.000-08:00

It was one of those meetings where logic just seemed to fly out the window and minutia took control and strangled what little common sense was left in the room. It is bad enough that the nurses don't have the time to take care of patients because they are so busy having to chart everything, and that the real care is being done by lpns. Well, here come the next level of making sure the paperwork is better cared for than the patient. The hospital is having to hire even more nurse practitioners. The reason? Since there is so much more time spent doing paperwork, well entering everything into the Federally Mandated EMR, the docs who used to see the patients and manage their care don't have time to actually see the patients. So, you have to hire a bunch of nurse practitioners to do yet a whole second level of paperwork, to free up the docs to be able to actually see the patients.

So, it used to be a nurse took care of the patients and a doctor managed their care. Now it is lpn who actually sees the patients, a nurse and a arnp who spend all the time documenting on the patient, and a doc who tries to see the patient and has to manage all the others paperwork.

I had to open my mouth. I asked if the nurse practitioners where going to actually see patients and write orders. I got the of course from the nursing supervisor. I asked what training do they have. She gave me a look like she wanted to kill me. She said, "well, they are BSRNs and then have their nurse practitioner's degree". I asked again, what again is their training. Before she could answer, I said, "if a patient is admitted by infectious disease, does the anrp have an infectious disease fellowship?, what about cardiology?" She said that some of the nurse practitioner's have been cardiac nurses. I said, "so she does cardiac patients only?" Of course the answer was no. I looked at the applicants for the nurse practitioner position. All of them had gone straight through school, there was no clinical experience at all. I told her. If your mother is admitted to the hospital with a pe and right heart failure, how do you want her care managed? You can have an experienced nurse watching her and taking care of her, or you can have a lpn and a arnp who doesn't have a singe ounce of clinical experience charting away to make sure JACHO and CMS are happy while the doc is getting pummeled by all the other anrps that are in way over their head.

About that time the hospital head administrator said something that made me like him a lot, he said "look, our job is to try to find out how to take care of patients and stay in business while the government tries to do the opposite."

Frank's Blood

2010-12-18T04:59:00.000-08:00

I familiar with A, B, O and even the rh blood types, but Frank's blood is in a league all by itself. It seems to only come from foleys, ng tubes, et tubes or chest tubes late at night. Its volume can not be quantified, it can not be typed, it can only be reported. It is always bright red but turns immediately brownish black whenever a MD inspects it. It will always saturate a dressing which can never be located to see just how much it was. The untrained often think it is Gross's bleeding which is quite hard to miss.

Vet Med

2010-12-16T05:43:00.000-08:00

One of my patients is a veterinarian who recently had surgery. She showed me her itemized bills from the hospital, surgeon, anesthesia and lab. She then showed how much her insurance paid and how much she had out of pocket. Lastly, she showed me the total cost. I wondered why she was showing me all this, since she was here for another reason. Then she grinned and handed me another bill. It was for the exact same surgery that she had performed on a dog. It was more and she got paid in cash!

Medicare Fraud(fraud)

2010-12-16T05:31:00.000-08:00

In the office we are always seeing patients who are on full Medicare and Social Security Disability who as near as we can tell are very employable. They are able to drive, play sports, shop and file endless complaints about everything. It came to a real head the other day when we had one of our cancer patients who has bone mets, pathologic spine fractures, intractable pain and partial hemiparalysis get his disability declined. All this while one of the "fibro" patients is mad because she might miss her golf luncheon.

Our ever wise, observant, master of all things receptionist, biller, scheduler decided to call that Medicare Fraud line that has been so common on the TV. (these are part of the multimillion dollar ad campaign launched by the government about reporting Medicare fraud). She tried to report suspected Medicare and disability fraud. Turns out, there is no where to really report it. There is really no one to talk to. In fact, they don't care. So, she called the Social Security Administration. Guess what? She got the same thing.

Just goes to show you, reporting Medicare Fraud is a fraud!

Pathognomic Wisdom

2010-12-12T06:00:00.000-08:00

Saw Earl (not his real name) in the office this week. Earl is one of those people whose wisdom knows no bounds. He has shrapnel in his arms and his legs from a torpedo attack in the North Sea and scars from working the farm all his life. As I was sewing him up from an office procedure, Earl decided to impart some of his wisdom. Everyone who was free in the office came in because, when he talks, everyone listens.

Earl said that it seemed to him that the problem with politics and government is that people want other people to pay for things that they want. He said, here is how to fix it. There is your base tax. This is to pay for what the Constitution says the government is to do. No more, no less. There is nothing to pay for anything else that the government has tacked on. Then you put on your tax form a bunch of boxes that say, would you like to pay extra for any or all of these, and how much? That way, those that feel strongly about something that they want the government to pay for can chip in and the people who don't want to pay for it wont. "I call it ala carte taxes." You want an earmark, put it in the form. People and politicians will find out real quick what people really want to pay for. Also, this way, the people set the budget, not the politicians. Also on the form you can have boxes that say, the government has no business paying for. Seems to me, we fix things real fast if we do it this way.

Procrustean's Bed

2010-12-08T08:57:00.000-08:00

One of my biggest gripes about what has happened to health care is that there is more taking care of paperwork than taking care of patients. Anyway I was between cases and going though the patients chart looking at all the stuff that has to be entered. (You know electronic records are supposed to save time!) and of course all of the record requirements are JACHO and CMS mandated. On the patient intake there is a whole section on psychiatric symptoms including where the patient is to be asked if they had any suicidal of self destructive ideation. Of course, this has to be documented. The only issue was that the patient was from the NNICU and was 4 days old. A RN had to enter all this. Even though it was N/A all through it, the nurse still had to do it instead of watching and taking care of their patients!

The Null Card

2010-12-04T14:14:00.000-08:00

Its rare that we ever get drug samples these days. The feds have basically chased them all away. I really thought the sample meds helped as I personally hate it when you had someone go get a prescription only to find out it didn't work. The samples were also a good thing to help out our indigent patients.

Anyway, I saw an elderly lady in the office yesterday. Like many Seniors she has Social Security and Medicare and is barely making it. She needed a medication that she just could not afford. For that matter she could barely afford food. We called around, searched and begged and finally got a sample card that gives you the first month of the medication free to try. We were so excited! Then we read the card, it was not valid for anyone with Medicare or Medicaid! We looked at all the other vouchers and discount cards that we could find. Guess what, they all said the same thing!

Obamazeebub

2010-11-28T17:26:00.000-08:00

This is what you get when you make a deal with Obama and his minions.

http://blogs.wsj.com/metropolis/2010/11/20/union-drops-health-coverage-for-workers-children/

ACLU Healthcare screeining

2010-11-22T17:14:00.000-08:00

I was watching all the talking heads on TV discuss the TSA screening issue and how people are chosen at random to be checked as well as those who refuse the scanner. One of the commentators seemed to hit it on the head when he said "look, we cant just screen and pat down Islamic travelers who are traveling by themselves with one way tickets that are paid for in cash. That would be profiling! That is what the ACLU has filed suit about!"

I though about it and wondered how that would affect the practice of medicine if we followed the ACLU anti-profiling school of thought. We would be ordering PSA levels, pregnancy tests and sickle cell smears on every 80 y/o Caucasian female. Of course every male would need to have a pregnancy test before surgery not to mention a mammogram. We wouldn't want to profile of course, that might be discrimination.

HIPPA Tax

2010-11-21T16:47:00.001-08:00

As usual I spent I spent part of the night waiting on the OR for yet another urgent case that would not be urgent if the patient went to see their primary care doc earlier. Well, that is if they could. They had Medicaid which is worse than having no insurance as no doc can afford to take it but that is for another post. Anyway, I was looking at their paper chart. Yes, even though we are on electronic medical records, there is still a paper chart. Guess what it is filled with? HIPPA forms. Over 22 pages of them. Some are the faxes that we have to send to get electronic records, others are all the medical information waiver forms. A lot of trees died for HIPPA. This got me to wonder. When the government passed HIPPA did they have a CBA estimate that said, hey this is going to cost the economy billions, and this cost is going to be taken away from taking care of patients? Lets see, we have all the manhours of staffing that it takes to make sure all of the paperwork for HIPPA is done. We have the HIPPA compliance consultants, we have all the increased costs of the EMRs to make them HIPPA compliant. There is all of the paper and the extra faxs. Then there is the government HIPPA auditors, not to mention the increased liability for a HIPPA breach. I'll bet it is in the billions.

I started to think about how much JACHO costs and how all that money could be used to actually take care of patients, but I stopped myself because it is not good to go into surgery p****ooo****!

Even God cant afford ObamaCare

2010-11-20T14:19:00.000-08:00

We just had one of our hospital staff meetings. I was surprised because the place was packed. This is a good sign that something big was going on and I was out of the loop as usual. The medical center was announcing its latest cuts in services. To justify the cuts it showed the financials of each department. OB was a bottomless pit, anchor babies parents tend to not pay thier bills. The only things that made a proffit in the EDs was the parking garage. Then they went into Obamacare. Because of the higher copays coming up this year they expect a huge drop in the elective procedures. Not one of the private insurance companies is offering a contract that will offset the increased costs of Obamacare and the number of uninsured is skyrocketing. The good news was that we are still in business. We looked at some of the other medical systems. Catholic Health Partners which is one of the biggest truly nonproffit, send us your poor is selling off hospitals, equipment, everything. In many areas they are the only rescue net there is for the needy. You know something is bad when even God cant afford it.

Judicial Review

2010-11-20T05:02:00.000-08:00

A few years ago one of my partners was raked over the coals in a medmal lawsuit. He won the case but it tore him up emotionally. It was one of those cases where bad things happened and he just happened to be there. Early in the case the plaintiffs attorney kept calling to settle, dragging it out as much as possible in the hopes to just get some cash. My partner and his defense team just said it was up to the court. When it finally went to trial, my partner won, but at a huge cost. He is one of the most caring people I have ever met.

Anyway, I was in clinic and it was chaos. I was on call so I had my patients and then all the ER calls. Right in the middle of it my partner comes around the hall and shuts the door. He says "Remember my lawsuit? The Judge is here. He has a big " " mass that was found and remembered me from the case. He wants me to do the surgery. I asked him why me, and he said it was because all the experts witnessess on both sides seemed to agree that you were one of the best."

Obama and Newtons Third Law

2010-11-16T18:30:00.000-08:00

I have noticed that Obama seems to be a physics major as everthing he does seems to follow Newtons third law. This came very true last night when we had a big board meeting where all the health insurance providers for our staff presented their contract offers. The cheapest that would let our folks keep their same coverage had a 27% increase. BlueCross was 43%, United Health 37%, Cigna 54% and Aetna 51%. Perhaps, instead of having him push a bill to decrease our healthcare costs, we could get him to push and pass one to raise them?

It is what it is

2010-11-14T05:43:00.000-08:00

I was listening to several of the news talkers the other day. They were having a big argument about being conservative and liberal. I decided that I think the big argument is about those who are "it is what it is" and those who are "it shouldnt be that way". I think that both are ok because the former deals with the situation and the other tries to change things and somewhere in the middle is a good thing. The problem I see the most though, is when those that are in the "it shouldnt be that way" camp refuse to accept the situation that is present.

I had that thing happen just the other day. I had a patient in the office who is a local liberal radio personality. On his show there was an argument about "dont ask, dont tell" which he really hates. A caller asked the host if it was ok for men to shower with his daughters. He said no. The caller then asked if men shouldnt shower with his daughters, why should gay men be allowed to shower with other men? The host got flustered. He then said, "people dont always get sexually excited in the shower". The caller said, why then can men not shower with your daughters? The host got slustered and then fell back on "it shouldnt be that way".

I had to give the host some medical news. It didnt go so well, all I got was it "shouldnt be that way". The problem was, it was what it was.

Action Auto Medicine

2010-11-07T05:24:00.000-08:00

I just saw a potential way to fix our medical system by watching a young 20 year old man at Action Auto. He was amazing and far ahead in wisdom and insight. I was there trying to get a idle air control valve. When I went to the counter and told him what I thought I needed, he looked at me and asked why I thought I needed it. I explained what the car was doing and when it was doing it. It would stall at idle so I had to drive with one foot on the brake and one on the gas. He said, we can put it on the computer and run all the tests and then check the mass airflow sensor, the down stream O2 sensor and change the fuel filter, or we can go with the most likely and blame the idle air valve. He then said, there are a bunch of ways to fix a problem. If you want it fixed permanently, you can pay $80 bucks for a new valve. If you want it fixed for awhile, you can just go hit the one in your car with a hammer as it is most likely just stuck. If you want you can try to clean it out, but just keep a small hammer in the car so every six months or so you can just whack it. I thought about it, walked outside to the car. I didnt have a hammer but I did have the baseball bat that cracked at the last game. I whopped the valve and the car ran just fine.

I bet if I had insurance and did not have to pay out of pocket I would have said run all the tests and then I want a new gold plated top of the line valve. Since everything was out of my pocket, I went with the cheapest, fasted way. Of course the Action Auto guy was not responsible if I did something stupid or if my car died and I got into or caused an accident.

Grim Reap what you Sow

2010-10-31T20:05:00.000-07:00

We knew that it would happen, but how do you explain business to people who have never been in or ran a business. In healthcare, the private insurance elective procedures generate the revenue that covers the expenses of all the other care. We told our Blue Dog that if the healthcare bill goes through, private insurance will cost more, patients will have higher deductables and will therefore not have the procedures that pay the bills to keep the hospitals open. They didnt listen. People cant afford to have thier total joints, knee scopes and such and as a result hospitals are going broke and cutting services. So, they "expanded healthcare" by making sure that there was nobody who could afford to give it.

They also said that people who are high risk could buy insurance in "co-ops", these dont exist, so these people dont have insurance and still need medical care. The hospital in the Blue Dogs home town is now closing at the end of the year.

1-900 Healthcare

2010-10-29T21:33:00.000-07:00

I decided earlier in the week to see how much of my clinic I could accomplish over the phone if I had too. It was astounding. I figured out that at least 45% of the patients that I saw in the office could have been diagnosed and managed with a brief phone call. Many of the pateints were consultations from other doctors who just wanted a specialists opinion, others were just follow up.

I then started to wonder. We see the pateints in the office because that is how we get paid. What if we got paid for the phone calls? What if the standart of care included telephone consultations? I could see a lot more patients so the shortage of specialists in rural areas might be decreased. The cost of these consultations would be cheaper.

Oh, wait a minute. The last thing Medicare would ever do is something that would allow more patients to be cared for in a cheaper way. Afterall, they set what is and what is not paid for.

Magical Thinking

2010-10-09T16:39:00.000-07:00

Late last night several of us were in the little office in the ER while we waited for the OR to get ready for the second of the emergent cases of the night. One of the ER docs was there watching the news that was showing some of the Presidents speeches of the day. The ER doc went on a kept muttering, "Magical Thinking". I asked what he meant by that and he said, "he says things like he thinks that just by saying them they will come true, you know like jobs, economy, the whole bit. Just look at him, he is about to have a major psychotic break!" Before I could ask further, we had to go to the OR but I couldnt help but wonder. If the president does have a psychotic break, who makes the call? I mean, is there someone whose job is to keep track of the sanity of the commander in chief and Baker Act him if he goes supratentorially dysfunctional? If he does get Baker acted, is there some plan set up to have a competency hearing? Who is part of that hearing? For that matter, does a presidental canidate ever have to pass a psychological evaluation?

Not the Patient!

2010-10-08T17:36:00.000-07:00

There are many times when a patient comes in with either a family member or friend who tries to hog the whole patient visit by talking about their own medical problems. I had one today who didnt even let the patient get a word in edgewise. The patient's friend wanted to talk about her own bypass and how she had all these test. I finally had to explain that it was her friend medical issues that the visit was for. No sooner had I said this then she started talking about how she had belly pain. Eventually, I interupted and asked the patient if I could talk to her in private and asked the patients friend to step out. With the friend out of the way, I was able to talk to the patient and get her the treatment she needed. The patient's friend used the time out of the room to fill out a survey that said I was rude and inconsiderate. I wanted to tell her that it was a patient satisfaction survery and she was Not the Patient!

MBA Medicine

2010-10-03T07:33:00.000-07:00

It was one of those meetings. I was the only physician or medical person for that matter at the governance meeting of the medical center. Everyone else was either a businessmen, accountant or lawyer from the administration. One by one they presented data on the finances of the medical center. Which DRGs we made money on, which we lost on. Then came in the team for marketing. they showed us the demographics of are area, age, income. They explained that we needed to be focusing on certain patients with our advertising and our services so they would want to come to our medical center. With each presentation, the term patient was lost and customer was substituted.

When the presentations ended there were all kinds of questions about how to market to the "customers" and why certain ones do not come to the downtown hospital. Finally, it was my turn. I asked "Where do our patients come from?" I got the look of looks, and then with exacerbation, the MBA of marketing pulled up the slide of the demographics of the referral area. I just look at him and stared. Finally, I said. "Look, patients have primary care docs. You chased them all out of the hospital. They want nothing to do with you. When Mrs. Smith calls her doctor because she is not feeling well, he is going to tell her where to go. Hospitalists are great, when they work with or for the internists and family docs, not when they work for and only for the hospital. When is the last time you have seen or talked to any of the primary care docs in your pretty demographic slide?"

"If you want to market, work with the primary care docs in the referral area. Show them that you are going to give their patients' the best care. Streamline admissions, testing and follow up care. The referring docs are your customers." "If you want to market you are the best heart center, convince the PCPS and the outside cardiologists." "Ms. Smith is going to go where her doctor tells her she will get the best care."

The rest of the people at the meeting just started at me like I was an alien and then began to discuss their confustion why the biggest Ortho group was moving its cases to the other medical center.

Puttin it Bluntly

2010-09-25T04:46:00.000-07:00

It was the usual type of case in the OR. As I went to sew up the fascia, the needle wouldnt go through the tissue, in fact it broke right in half. We then spend the next five minutes trying to free the piece of the needle that was stuck in the tissue. When I looked at the package, it was the usual 3-0 vicryl SH but then it said "blunt"!

It turns out that a while back there was a study that showed there may be a decrease in accidental needle sticks in OR personnel if blunt needles were used because they were less likely to penetrate a surgical glove. At one point it was even recommended that they be used in some closures. On more careful examination, it turns out that the real reason there were less needle sticks was that the blunt needles were useless and pushed to the side.

So, some government suit decided to mandate blunt needles (OSHA and JACHO), so all the needles were replaced without letting the surgeon know! I had to to fill out 3 forms for each needle that I use now that I want sharp to satisfy these new mandates!

I wonder what will happen next, will they take away scalpels and make us use plastic sporks?

Yellow Omega Sign

2010-09-23T19:04:00.000-07:00

(on the inside bottom corner of the patient chart) One of our internist was really upset today. He is one of the most caring physicians I have met. He was beside himself. It turns out that a patient had demanded narcotics and he said no. As a result the patient went onto a physician rating site at slammed him so that if you Google his name, that rating turns up. That made me wonder. If patients can anonomously rate docs, why cant docs do the same for patients?

When I was a resident, we would put a yellow Omega sign on the inside bottom corner of patients charts who were crazy or obnoxious. That way the poor sod who had to take care of them next would be prepared. I wonder how we can do that now in the digital age? Think of it, we could identify those that are faking disability, those who are hypochondriacs, those who are noncompliant, drug seekers, the whole bit.

Jackpot ala ATLA

2010-09-22T05:09:00.000-07:00

This pretty much sums it all up!

http://vimeo.com/15137268

Redirect ala-Michelle O

2010-09-11T07:39:00.000-07:00

It is bad enough to have hospitals dump patients on you but now with all the healthcare changes, they are following Michelle Obama's plan as well as her husbands. Becuase everyone's health care costs are going up and this Medicaid expansion means no one can afford to take care of those with it, hospitals are following Michelle Obama's South Side (of Chicago) Healthcare Care Initiative. Before the patient even has a chance to enter the hospital, they are met by a person who encourages them that it would be better for them to go somewhere else and they will even pay for the cab or bus ride to get there. This is exactly what she devisedd when she was a VP of U of C in Chicago and even had David Axelrod promote it.

So, we are now having patients arrive not by ambulance but by cab and airport limo!

Candyman, Candyman,Candyman

2010-09-11T06:01:00.000-07:00

I had a patient say to me " wow, your the Chief of Surgery, you must be good". I wanted to puff up and say "of course", but told the truth. I explained that I missed too many meetings so the ones who were actually at the meetings mad that they were there voted me in when they went down the list to see who hadn't already done it.

Anyway, part of my duties as "Chief" is to be the physician who oversees the risk management committee. It is amazing at what it tracked, everything from patient complaints, to infections, to food quality. On my desk last week was a thumb drive full of data from the ED. Outcomes and encounters are all tracked. They are broken down by diagnosis, provider, and shift. In all these data streams, we look for trends.

One of the things that jumped out was that there was a big difference in the number of patients seen by different physicians, this was independent of shifts. It also showed that the physicians were seeing the same number of true emergencies but that the difference was in patients there for back pain or "acute fibro". To find out what was going on, I called over to our head patient registar for the EDs. As a side note she is amazing. When people ask her how long she has been there she tells them that she was always there, they just built the ED around here). Anyway, she explained it all. She went down the list of docs and said, Candyman, Candyman, Candyman, HardA***, HardA***, B*****, Candyman and so one.

Sure enough, she matched the list. The word gets out quickly which docs are in the ED. In fact, people call the EDs to see which doc is where. The Candyman docs will write for a little pain meds to get you through until you can follow up with your own doctor for your long standing pain. After all, your "pain is a vital sign". When there is a Candyman, everybody runs to the ED to claim that their pain is "horrible" to get their fix. When there is a HardA***, the ED is quiet. She even explained to me that they alter their staffing depending on which providers are where.

As I was leaving she took a piece of paper off the stack of Memos next to here. It was from the med center administration. It was about a decrease in the Press Gainey scores for the ED during certain shifts. It recommended that they try to find the problem and then report back. I looked at the memo and then went to the office. There on the flash drive was the Press Gainey data. You guessed it, the scores were higher for the Candymen!

Chicken Little Syndrome

2010-09-08T18:19:00.001-07:00

One of the problems we have in the ED is people lying about their symptoms to be seen sooner, or to be seen by a MD instead of a ARNP or PA. With the ED filled with people who really dont need to be there, some people who also dont need to be there think that they can lie about their symptoms and get in faster. Mind you our triage nurses are pretty adept at determining who is and is not reatl. This weekend though one got through the cracks. He was in the ED trying to get an excuse for missing a meeting with his parole officer. He thought he would tell the nurse that he had chest pain, then when he got back explain that it was his ulcer that was bothering him and get a script and go home. Anyway, before he could say anything they hooked him up to an ekg and he got his wish, he was right back. In fact he was right back through the ED and straight to the CCU and then to cardiac cath. He kept trying to explain that it was his ulcer and all he needed was an excuse. The third degree block on the EKG said different. Turns out he never really had an ulcer, he has a new bypass though and by the way he got an excuse for missing his next parole officer meeting.

Acute ORS

2010-09-07T17:54:00.000-07:00

I was the "man in the barrell" over the Labor Day Weekend. It was like being the only duck in the shooting gallery. Patients were being dumped from four states as fast as the ambulances could carry them. The outlying hospitals were doing all they could to get rid of the nonpay medical liabilities. Six were children who had health insurance but the parents had got rid of it "cause they were getting it free from Obama". I guess nobody told them that SCHIP was broke in their state. One was a former Teamsters local president who had worked for a trucking company that went bankrupt. He was a local guy who even appeared in an Obama commercial. Several were elderly patients who couldnt get in to see a doctor and had let their problems get so out of hand that they were immediately turfed.

It seems that acute ORS (Obama Regret Syndrome) is spreading like an epidemic. Unfortunately, it has already destroyed the medical system that could have treated it.

Red dab of health!

2010-08-20T11:23:00.000-07:00

I was sitting in the lounge when somebody brought up MRSA infections and saw that WhiteCoat did a geat article on it in his blog. I wondered.

Did anybody notice that the superbugs began to emerge at the same time the FDA banned mercurochrome? It is extremely active against all strains of staph and gram negs. In fact, it is one of the most effective topical agents.

The FDA banned it because of the mercury which was never shown to be absorbed to any degree or to lead to any problems. Just like the thermosol scare, mercurochrome became the enemy. Even though it is now proven to be very safe, no one will produce or sell it because of fear of lawsuits.

Like many sureons, I add a bit of bleach to the bath water every now and then to help decrease staph colonizations but I think I am also going to bring back some mercurochrome from our next mission trip! (That it, with the way things are going with healthcare, the next medical mission trip may be to Washington DC!)

Whoop, there it is!

2010-08-17T17:35:00.000-07:00

California so far has had over 1700 reported cases of pertusis with 7 infant deaths so far. This does not count those that have died that there was no post on. 2700 confirmed cases so far. Since it is very hard to test for the number is probably far more. This is the worst epidemic in at least 50 years. So where is Jenny McCarthy and the dont vaccinate your kids groups? Where are all the attorneys that tried to sue claiming that vaccines caused autism? There are at least three schools in California (according to NPR) where 80% of the have not been vaccinated. Just wait until those schools have an 80% rate of polio.

If Doctors were paid like attorneys

2010-08-14T20:31:00.000-07:00

I think it is interesting to hear attorneys argue about how doctors should get paid. I wondered what it would be like if we were paid like attorneys. First, you would call the office to see if the doctor would consider your case. After talking for a bit with a paramedical you might get an appointment to discuss your possible case with the doctor. After consideration, he might agree to take your case for a retainer and then a cost structure of so much per hour (hours that only he can determine and not verify) plus expenses. You would also have to sign an arbitration contract. Any calls to him would cost at least $200 and then $200 for each 15 minutes. There would be additional charges for documentation, travel, etc. The retainer would have to be paid up front of course.

In the event of a serious problem or one in which the patient client does not have the cash, the doctor could take the case on a contingency agreement where if the patient survives, the doctor gets 1/3 of all future earnings, plus expenses, time etc.

Better yet, lets pay attorneys like doctors. If you show up at the court house, they have to take care of you regardless of your ability to pay and you can sue them at any step.

No-can

2010-08-11T06:54:00.000-07:00

Got a call that one of my partners patients was a bit somnolent and hard to arouse after the family decided he was hurting in his sleep and got a bit agressive with his PCA. When I got he was holding his sats with a facemask but I wasnt sure how much was the morphine vs something else going on. To help determine this I asked for some Narcan. Turns out there is a shortage. Two of the companies that made it have stopped. It was going to cost them too much to jump through all the FDA hoops. Another company did not say why they stopped making it. The last said it wasnt sure if it was going to increase production or even continue to make it.

We stole some and got the pateint better. Good thing the FDA has stepped in to make it so hard now to produce generic drugs and to make it so easy to sue!

Camión Basculante

2010-08-06T10:32:00.000-07:00

Our county hospitals are going bankrupt. One of the main reasons is the number of illegals flooding their EDs. To stay afloat they have had to resort to new techniques. The technique is EMTALA. It is so hard to prove an COBRA violation that the small hospitals will immediately create some reason that they can not provide the care for the patient. All illegals who are pregnant get transfered becuase of lack of prenatal care and probable high risk. Of course all traumas, and everything else they can make up gets sent on the camion busculate to the university. Somebody has to pay the bills, so pass the buck!

Tomcat Social Economics

2010-08-01T06:19:00.000-07:00

Our accountants moved into an old historic building (for tax reasons, but that is another rant). One of the first things they noticed was for an old building, there was not a mouse to be found. They soon discovered that a small Tomcat was living just behind the building in a small crawl space. Some of the people decided it would be nice so they started feeding the Tomcat. Before they knew it, they had mice everywhere. You couldn't leave your lunch uncovered while you went to the restroom because a mouse would be there. The Tomcat got fatter and fatter. Infact, if you didnt feed it, it would go from window to window crying until it got something. Then it wanted to be fed more and more. Soon, there was not only the one tomcat, but a whole bunch of cats. They were everywhere! All whining for food. The original tomcat was so fat, he couldnt catch a mouse if he tried! Becuase there were so many cats the cat poop was everywhere! The accounting group had to have a called staff meeting about the cats. The cost of the exterminators to take care of the mice was astronomical. Clients were offended by the cats and the odor. In the meeting the people who were the ones who started it all complained that they just couldnt stop feeding the cats, somebody had to take care of them! When all was said and done, the group decided that no one was to feed the cats, if someone felt strong enough that the cats needed support, they could take them home!

Interesting thing. The cats mewed at everyone and screamed through the windows for what seemed like weeks, and then went away. The exterminators caught up with the mice. A few weeks later there were couple of cats living in the crawl space. They could be seen in the morning hunting mice. No one saw any mice in the building.

A Sith Lord

2010-07-31T04:34:00.000-07:00

I received this in my email this morning.

What, that cant be you say. Or can it? Consider the following.

Barack Obama became the leader of the free world after a brief career as a virtually unknown and unimportant US Senator. Chancellor Palpatine became Emperor after a brief career as a virtually unknown and unimportant Senator from Naboo.

In 2008, Barack Obama campaigned on a platform of "Hope and Change", (after a carefully orchestrated crisis). Similarly, Chancellor Palpatine, prior to seizing emergency powers and declaring himself Emperor, raised everyones hopes at the prospect of ending the Clone Wars. (after a carefully orchestrated crisis)

And take a look at this Obama speech here at http://www.youtube.com/watch?v=ItHtOqh2Yk0 . I could swear he sounds just like Palpatine.

Coincidence? Sure, That's what THEY want you to think....

DoctorBashir

(my little edits)

Driving Ms. Disabled

2010-07-29T09:49:00.000-07:00

It was one of those days. I lost count of how many of the patients I saw were "disabled". I mean, full fledged, on Medicare and Social Security disabled. One was 28 and was disabled due to chronic pain from her obesity. Another was 30 and was disabled because of headaches. Of course, there were the buch with fibro. The one thing that got me was, all of these people drove themselves to the office. They are so disabled that they cant work and get free healthcare as well as checks from the govt, but they can drive! Why cant they get a job driving? For that matter, why cant they get a job putting gas in cars? They all are very good at talking on the phone and texting while at the visit, why cant they get a job doing that?

If the government wants to help decrease the fraud in Medicare and Social Security, I suggest that it revokes the drivers liscence of anybody who is on Social Security disability!

Add a D to the MD, Drop the M for an S

2010-07-23T15:03:00.000-07:00

It is hard enough to get qualified applicants to go to medical school, much less into surgical specialties but now this one takes the cake. We had one of our interns leave the surgical program, to go to dentistry. Not to be an oral surgeon, to be a general dentist. I cant fault his decision making, he put it this way. He will be his own boss. There is far less regulation. Obama hasnt messed with it yet. It can be cash pay and you dont have to deal with insurance if you dont want. Dental emergencies are not covered by EMTALA. If you dont pay, you dont get squat.

He was our sharpest intern.

Obamatrophic parasites

2010-07-21T08:51:00.001-07:00

Parasites are a problem, but they are a fact of life. They live by feeding on the host, taking not earning. Many organisms have atleast learned to use them, at at least get something from them. These organisms have made the parasites, biotrophic parasites, parasite that actually can help the host. They are not symbionts because the host can live well without them but at least the parasites are partially paying their way and the host might actually do better. Like all parasites, however, if there are too many, the host dies. There are also necrothrophic parasites that just eventually kill the host. Then there are Obamatrophic parasites. These are necrotrophic parasites that just live on the host and try to multiply to the point that the host dies, and biotrophic parasites that are organized to believe that they dont have to contribute to the host anymore and in fact that they are entitled to the hosts resources. These Obamatrophic parasites work only to support the condition that helps them not contribute.

I operated on a HR rep from a large company. They are looking for 300 people. The jobs start at $13/hr plus benefits. They cant get enough applicants (well there are enough but they are illeagals). Why would you want to go to work when you can get $300/week for free from the Feds and state, free healthcare, housing, food? Especially when it is just extened for another 4 months. Hey thats over two years of just sleeping in, watching TV and playing XBOX! Why would anyone want to work?

You Know, the blue one!

2010-07-20T20:36:00.000-07:00

I should not have done this, but I could not resist it. I was picked to give one of the short welcome lectures to the new interns. (again, I blew off a meeting and look what happened!) Following my administrative motto of "do it good enough that you dont get in to trouble but not so good that they ask you to do it again," I titled my lecture, "Things that they didnt teach you in medical school." My first slide whas a pile of different colored pills. I explained that many times when you ask what medicines your ER patient takes, they will tell you that they take "one green one, one blue and two yellow". If you ask if any of them are blood thinners, they will look at you like your are stupid and say "you know, the BLUE ONE", but I only take it when I think my blood is thick. When you ask if they have any medical problems, they will say no and have no idea why they are on the blood thinner. They will deny that they have had any major surgery but you will notice the medial sternotomy scar and the off center midline abdominal incision.

The next slide was the "yellow pill". At least it was yellow from this pharmacy. It was hydrocodone. I explained that this pill makes everyone hurt. Because they take hydros all the time, they will tell you everything hurts becuase their pain receptors are messed up, so you cant tell what is what. (you will wish the previous doc left a little chip like dogs have in the wound so you could just scan the patient and find out what was done.) They will have no idea what their abdominal scar was from and will look puzzled at you because you asked. (the scar is supposed to tell you what surgery they had.) They will all be in so much pain that they cant do anything, except they can walk outside and smoke.

The next slide was a wooden shoe. I explained that their are many people at the hospital to help you, but dont rely on them or believe them. Double check everything becuase you cant tell the saboeteurs from the allies. Check your own xrays and verify your labs. When you look at xrays, first check to see if it is the right patient, secondly look at the xray to see if there is anything in the xray that might kill the patient, such as your shadow!

The next slide was a phone. I said it is always easier to call and ask for help then it is to call and ask for forgiveness. Lastly, I said, if you dont know spanish, start learning!

I think I will probably not be asked to do this again.

Throck Multi-tool

2010-07-20T20:13:00.001-07:00

I was in my usual state of disbelief last night on rounds. Why is it so hard to get a pair of surture removal scissors or a staple remover? Why can you always find the hemocult cards but never the developer? It seems that to make it through rounds I end up hoarding all these things so that once I find them I can put them in my pocket so I dont have to hunt them down for the next patient. Then I got an idea. I love my little Leatherman multitool! It has got me through camping trips, military deployments, and car break downs. Why cant we come up with one for medicine? Kind of a swiss army knife for docs.

Then I started thinking about what it should have. It needs suture removal scissors and staple removers of course, but what else? Flashlight, stethascope, #3 mac blade, hemostat, 16 guage needle for those darned popped lungs, could add one of those portable US things, oh, something to remember all those darned EMR passwords that change every few days at all the hospitals we have to cover, nurse GPS locator, food finder, hemocult developer, gloves, culture swab, IV pump shut upper, bandage swabs, cast cutter and above all bad odor eliminator.

The device would have to be disposable of course and I would have to get it JACHO mandated. Oh, wait a minute. They would keep them locked up in the Suremed and you would still have to find a nurse and get the patients number to get the thing out anyway.