I dont have to think so I cant be accountable!

Beeper keeps going off. There is a new JACHO policy about pain medications, you cant write in the post op orders, Morphine Sulfate 1 to 4 mg IV q 2 hours prn pain. You must write, if pain on pain scale is 0-1 give no morphine. If pain is 1-3 give 1 mg morphine 1v. If 3-4 give 2, and so on. Gone are the days when the nurse was able to watch the patient and keep them comfortable by asking them about their pain and watching their vitals using their experience and wisdom to guide them. Now the attitude is dont let the nurse think, just let them do paperwork. If they dont have to use judgement then they dont have to be accountable.

Oh, I forgot, before the pain medication can be given, the nurse must document what pain was on the pain scale. I know that most of my patient who are waking up from surgery are in pain but can only raise one finger to show their pain scale. It is of course the middle finger which is raised when they are shook violently to wake them up so you can ask them about their pain scale.

Cachexic Healthcare

The timing was perfect. On the way to a meeting I was listening on the radio to an Obama Administration spokesman saying that that the Administration has saved millions of jobs and made new ones and she pointed to healthcare as an example. The meeting was for the Executive Committee of the hospital which is where the clinical staff and the adminsistration try to mesh the two to provide the best care possible given the monetary situation. At the meeting, the administration dropped the bombshell. The hospital loses money on self pay, Medicare and Medicaid and makes up the difference with the private insured. Well, the number of the private insured patients has plummeted. Since the main money is made on elective procedures like total hips and knees, and people are holding off on these, the medical center is going broke. This is despite the fact that hospital is 85 to 95% full on average. A huge cut in Medicare is also coming and the Obama Administration and Congress is getting rid of the tax breaks that hospitals got to take care of the indigent. Since by law the hospital has to provide its services and it can not turn anyone away who comes to the ER the only place it can cut costs is staffing. So, as of this Monday 25% of the medical center's staff will be laid off. Four of 12 associated community hospitals will be closed and all outpatient physical therapy/occupational therapy and infustion centers will be closed.

I guess I should look on the bright side. The other medical center is cutting 30%! I guess Obama's spokesperson hasn't been to a hospital lately.

Using Restraint

One of my biggest peeves is the ever increasing paperwork load that keeps nurses from actually taking care of patients. Well, JACHO and CMS are at it again. Somebody without a clue complained that there are nursing home patients with dementia are restrained and therefore we need to completely regulate the use of restraints with tons of new paperwork. No one bothered to explain to the regulators that the nursing home patients have dementia which means that they dont remember that they cant walk so they try to stand and fall and hurt themselves. Anyway, JACHO and CMS came up with all these new regulations for the use of restraints. So, here we are in the ICU where a patients who has ODed on xanax is waking from his coma and tring to pull out his IV, endotracheal tube and ng. Since he has to be restrained for this, the nurse must document every thirty minutes the need for and the degree of restraints. To comply with JACHO and CMS this is a three page form that must be filled out either on paper or in the electronic chart. Since the nurse is the one who has to do the documentation, you either need to get another nurse to watch the combative patient and take them away from their patient or you leave someone less qualified to take care of the patient.

I wonder how many pateints will self extubate themselves and die because of these new regulations? At least they will leave behind a nice chart.

Least Common Denominator

I know that many people feel that defensive medicine does not exist but I did a little controlled study to see just what happens. Here is how it works. When a patient comes to the ER, they often get admitted by one of the hospitalist services. These doctors see the patient and are the general managers of their care. Because of liability reasons, if the patient has chest pain rather than work it up themselves and assume the risk, it is an immediate cardiology consult. Headaches, neurology. Diabetes, call endocrine. Pretty soon you have consultants jumping on the patient like fleas on a dog. Of course each of these consultations cost money. If the patient has insurance, each consultant charges their fee. Now here is the study. I looked at whether or not patient who were indigent had more of less consults. The answer was that they had more. The reason was simple. Indigent patients are less likely to follow up and more likely to sue. So, you consult more to make someone else responsible. As one of our ER docs put it, you are recruiting co-defendants. So, it seems that the least common denominator is not money, but liability.

Baker Act vs Stark Law

For those outside of medicine, Democratic US Representative from California Pete Stark is the one who has added many laws to regulate medicine into other bills to hide their initial effects. Many of us consider his laws to be at the root of why their is not more competition in medicine and why it is regulated into a beurocratic mess. Anyway, if you had any doubt of Congressmans Starks sanity, here he is explaining that "the more our country is in debt, the better we are off" and many more of his great "insights"!


http://www.youtube.com/watch?v=UjbPZAMked0&eurl=http%3A%2F%2Fjs%2Dkit%2Ecom%2Fapi%2Fstatic%2Fpop%5Fcomments%3Fref%3Dhttp%253A%252F%252Fglobaleconomicanalysis%2Eblogspot%2Ecom%252F%252F%26path%3D%252F2009%252F06%252Fus%2Dsavi&feature=player_embedded

I wonder when some California physician will just use the Baker Act on him in the middle of the House of Representatives?

Agricultural Stimulus

I got to see an old patient in follow up. I love him to death and he has been fighting different cancers for years. As I looked for another, I teased him about the smell of smoke on his clothes, by saying "Gosh, how much are those cancer sticks now with all those taxes?" His answer was priceless, "I know that you cant get around death, but the taxes are easy!" Before I went into my stop smoking talk with him for the 50th time, I had to ask him what he meant. Well, he is an old farmer and it isn't that hard to plant a half acre of tobacco for his personal use and the use of some of his friends. Infact, they have sort of a co-op. He grows it, another person cuts and drys it while another grinds it. They then roll their own. He did confide that sometimes people give him some money for it. Turns out enough to pay the rent. As to the taxes, he said "I'm 79 and I have had cancer 4 different ways and it aint licked me yet, I'm going to roll in that social security as long as I can until I break even on all the money the governement took from me!"

I wonder how many others are growing tobacco in their gardens?

COPD vs Obamanomics

In several ways patients with COPD (Emphysema) are like small business. In these patients the lungs are having a hard time getting oxygen into the blood. As a result the patients body compensates. As the lungs start to fail, the body starts shutting down all nonessential functions. The pateints lose weight, the kidneys and other organs barely function. To keep things going, the body then concentrates the blood by making sure that every cc of blood has as many red cells as it can to carry the vital oxygen to the deprived organs. The hyperconcentrated blood compensates for the lungs failure and the patients keep going. If these patients lose blood, bad stuff happens fast. Their body is already on the edge. You have to replace their blood. If you just give them fluid and dilute what blood they have bad things happen fast. In other words, you dilute the blood, they die.

Small business is very similar. As the economy decreases and people buy less, the business has to compensate. At first it can lower prices temporarily to try to keep the volume up. This is like breathing faster. Eventually however you burn up what ever profit you have and start to lose money. Because you have certain demands to stay in business (overhead) you cut where ever you can. Since the vital organs of a business are its employees, they get cut as much as possible. You then get to a point that you have cut all that you can and volume of business is low. So low that the only way you can stay in business is to increase the price of your product. This causes inflation because you had to raise the price just to compensate for the economy. This inflates the dollar because it takes more dollars to buy the same thing. So, what decreases this whole process? The answer is to decrease overhead or the stress on the system. For business, one of the big stressors is taxes! The other thing that needs to be done is to make the dollar stronger!

Instead, in Obamanomics you increases the taxes on business to further decrease their ability to stay afloat and mandate more costs per employee which speeds up and increases the cuts that have to made in the staff and lastly devalue the dollar by massive unbacked spending. So now you really have to increase the cost of your products just to stay in businees and really have to lay off as many people as possible just to stay in business. Thus raising unemploment and letting inflation run wild.

In other words, it is like a making a patient with COPD carry another patient on his back while running on a treadmill which you are making up hill while you literally suck the blood out of him.