CYA and Healthcare Reform

September 27, 2009

Ok, so I know that I haven’t written a post for some time now and you are about to understand why. About one month ago, my dad called me to tell me that his primary care doctor had instructed him to go to the ER immediately because his routine EKG showed a change from last year. She had in fact stressed him out to the point of probably giving him a heart attack with her behavior which included wanting to call 911 to take him directly to the ER from the clinic.

Was he having symptoms (chest pain, shortness of breath, diaphoresis, decreased exercise tolerance)? No. In fact, he felt totally normal. Was he having ST elevation or depression on his EKG (findings typical of heart attack or diminished blood flow to the heart respectively)? No. He had “nonspecific t-wave changes”. Were his vital signs concerning? No. His blood pressure was 128/72, heart rate was 88. So why call 911? Because the primary care physician wanted to practice CYA (cover your arse) medicine.

For some reading this post, the term CYA medicine might be something of a novelty. Certainly one never sees Dr. House, MD or Dr. Cox from “Scrubs”, or even Dr. Green and Carter from “ER” practicing this type of medicine. What exactly is this type of medical practice?

It basically involves the most limited degree of mental commitment possible in a medical encounter, where you are asking yourself only one question, “How can this patient hurt me later?”.  Based on the medical provider’s answer to that question, they then proceed accordingly. It doesn’t matter how much this will cost the patient – insured or not. It doesn’t matter how many needless tests you have to order at the patients physical, financial and emotional expense. It also doesn’t really matter if the patient agrees with you or not, especially if they are insured – because you can always threaten them with an AMA (against medical advice) discharge where their visit will not be covered by their insurance. They are your prisoner so you can strategize your defense from a medical malpractice lawsuit.

As an ER physician myself, I cannot always blame providers who practice medicine this way. I don’t believe that anyone graduates residency intending to practice medicine this way. Its after someone comes after you for something only God could have forseen that you get gun-shy. At the end, it becomes a vicious cycle of abuse from both ends.

This is the biggest problem with Healthcare reform – the hidden nooks that politicians can’t see the way we, as healthcare providers, see them from within. There are too many groups mining in the medical gold mine – malpractice lawyers, insurance companies, drug companies, etc. – and they each have powerful lobbies to back their interests. The purity and simplicity of the doctor-patient relationship with all that it used to contain of trust, friendship, understanding and forgiveness has been plundered and I personally am not sure we can return to that after having let in the greedy pirates mentioned above.

So, back to my dad. He asked me to come with him to the ER – in my car and not the ambulance – to make sure they didn’t rape him there with unnecessary tests and procedures. He had me stand behind the ER provider who was practicing CYA and give him thumbs up or down depending on whether I agreed with the management or not. They of course told him that he could die if he wasn’t admitted for “further testing”, but he did just fine at home until his next follow-up appointment.


Top Three ER Patients that Make You Go Hmmm

July 19, 2009
Anything but the needle doc

Anything but the needle doc

I have had this post on my mind for quite some time but it has come to the forefront due to some of my recent patient encounters. There are certain things in Emergency Medicine which are so strange and become even stranger because of the fact that it seems they are found in all other emergency rooms. Its kind of like someone getting a 1500 calorie fastfood meal and then ordering a diet coke – it doesn’t make sense and yet people everywhere seem to do it.

The first type of patient that causes many of us to just wonder – sometimes out loud – people with multiple tattoos, usually very large ones at that and often with the added variety of body piercings, who refuse to get a shot. Why you might wonder? Because they say they don’t like needles. It makes us wonder if their tattoos were painted on with a brush or maybe the kind you get out of a bubble gum machine. Piercings though – that’s like having a 10 guage needle stuck in you repeatedly – and often in some very sensitive areas as well. For the non-medical out there, we use needles that are at least half that size and sometimes only one third.

The second patient group that leaves us scratching are heads are those that come in with “vomiting”. This group is often divided into two categories: the truly sick and those who aren’t. Those who aren’t sick baffle us because they routinely insist on vomiting on the floor even though typically the waste basket or vomit-bin/bag/etc is literally within easy reach. I used to think that such people would never do such a thing at home, but after doing some EMS ride alongs and seeing some of the conditions that some people live in, I understand that they probably just vomit on their own floors/couches/chairs/etc as well.

As for those who aren’t so sick, its amazing how often they come in complaining of nausea while they munch on Doritos and drink some nasty grape soda or other carbonated sugar poison. One day I’m just going to lose it and tell them that maybe if they weren’t treating their stomachs like toxic waste dumps that they wouldn’t be nauseated. But usually, I just take the polite road and encourage them to do a bland diet for a few days and that they will likely feel better.

The last group that comes to mind – although their are a few others out there deserving of mention – are those that come in with a complaint that just started. “I have a sore throat”. How long have you had it? “Oh, it just started about 30 minutes ago”. Or, “my child has a fever”. When did it start? “I just checked their forehead 20 minutes ago and it felt hot so I rushed him in”. Granted if the patient has some extreme history, like they had epiglottitis or febrile seizure, I would certainly understand and do my best to reassure them – but come on.

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Creepy Love and Other Relationship Oddities of the Week: I

July 18, 2009

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From time to time in the ER, we have the unfortunate experience of seeing relationships so foul that they can only be called “creepy love” as a nurse so aptly put it one night. It is just the sheer volume of people that we interact with that necessitates, to some degree, that we see all sorts of oddities. To narrow it down to just a few is so hard that I decided this would only be one part in a mini-series. Prepare to be horrified.

Creepy Love #1  goes hands down to a mother and son team that came in last night. The son, a young man of 19 years, presents with mom because his testicles hurt. Ok, nothing weird so far. Before I go in the room, I see mom step out as he gets gowned, something totally expected. I figured she would stay in the waiting room till he got discharged. Wrong.
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As I start the exam, Mom returns. I tell her from behind the curtain that we are about to examine the private area and if she would be comfortable returning later. To my surprise, they both – almost simultaneously – say no. So, she comes back to watch me examine her boy’s family jewels.  Afterwards, we come to the a set of questions of what he was doing when his balls started to hurt.  I am totally amazed as he goes into a detailed description – again in front of Mom – of how he was making out with a girl for “a really long time” without hitting the pay-off at the end. So, I told him that most likely he was suffering from a case of  “blue balls” – or testicular vasocongestion in medical speak. 
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Mom very creepily laughed at this point and told me that this is what she had suspected as well. I thought to myself, “If she starts talking about how this kid’s Dad used to get blue balls when they were still a fledgling couple – I am outta here!”  Usually young men cross the – Mom, “this is kinda private” – line around 15 years old. 16 wouldn’t be weird. 17 is pushing it. College age is already weird. But 19 going on 20 is just creepy (this guy is about to start junior year in college).
 
Creepy Love #2: Young woman – 25 years old – presents to the ER after having a fall the night before when she was plastered. There is a gentleman (used very loosely) in the room with her who appears to be in his 50′s. I’m thinking Dad, but I learned a long time ago to not assume anything in this area (We’ve all been there before – “So, this must be your Mother right?” Patient’s wife replies in a very insulted tone, “Mother? I’m his wife“. Ohhh - can the Earth please open up and swallow me now please).
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So, I casually wait for a moment to ask the man, “And you are?”. He replies that he is a “good friend“. Another lesson that I have learned is that “good friend” can also mean any one of many things. Apparently, Mr. Good Friend was with this young lady at the bar last night and drove her home. So, I’m thinking maybe he lives on the same street – saw his neighbor trading sober for hammered and kindly offered to take her home. No, that would be too normal. This was all about the creepy.
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So, since she had fallen in her less-than-sober state, I needed to check certain areas of her that were still clothed. I told her to get gowned and that’s when the creepy-meter hit red. I walked out of the room to let her get undressed – and he didn’t.  Now I know you’re thinking, it isn’t necessarily weird for an older man to date a younger woman less than half his age, and that in some ways it can be totally socially acceptable. Believe me, this wasn’t one of those cases.  
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The last couple for this post wasn’t a creepy one at all, just a sad one. 55 year old man comes in with chest pain. There is a woman with him who looks like she fell from the ugly tree and hit every branch on the way down as well as ate bark. But I really do believe that beauty is partly from within and not only skin deep – so I really didn’t think much of it. Until I started the interview.
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Everytime this guy would try to answer a question, this woman would literally scream at him and say he was lying. Then she would tell me something else. He didn’t seem to fight it, so I could only assume she was right. It was more typical of the way an angry mother would correct her delinquint son, but this was husband-wife dynamics.
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When we got down to the social history, the guy turned out to be a regular drinker. Imagine that. I mean, who wouldn’t want to be sober to deal with a delightful woman like her everyday? To understand this dynamic better, I researched the net and found this interesting article: Top 10 Signs She’s a Bitch. Oddly enough, the first comment to that article was written by a man who called himself F@&k Me who wrote: “what happens when you’ve been married to one for 17 years, and just can’t take it anymore?”. I guess my patient was asking himself the same question everyday as he cried into his drink.

Some People Have Nine Lives Too

July 12, 2009
Medical Cynicism 101

Medical Cynicism 101

I remember someone giving me a book to read called The House of God when I was in medical school. I imagine that a lot of you have read this book as well. I thought that it would have been a better book had it not digressed so much into sex and I never really finished it for that reason. Looking back now at the some of the book’s ideas, especially that of the GOMER, a lot of it really rings true.

There are certain people that come to the ER that seem to command little to no empathy from all ER staff. They go by different names but they seem to make their way to all ER’s irregardless. They just don’t die, no matter what they – or someone else – does to them. They survive such extreme conditions that would kill even the most hardened average person a long time ago. And they just keep on ticking away.

I saw one such person in the ER this weekend. A staffer at the ED told me that he knew him well as he used to see him regularly when he owned a liquor store. The guy apparently had 6 kids with 6 different women (another f#^&er setting up franchises I noted), and was clearly proud of it when I asked him. This time, he was driving his motorcycle at about 100 MPH down the highway, weaving in and out of traffic, until he lost control. His bike slammed into the median strip ditch at this insane speed and he went flying into a field where he landed on his back. Of course, he wasn’t wearing a helmet. Would you or I have survived an accident like this? No. We would have died when the bike hit the ditch or even before that maybe. Did it kill him though? Not even close. He ended up with a broken collar-bone and first rib. He went home after a short observation period in the hospital.

Or not so long ago, when I saw a raging @$$hole in the ER demanding that I give him a prescription for ritalin. I had already looked into this guy’s long list of abuse (cocaine, meth, alcohol, narcotics, benzos, etc.) as well as the previous notes describing his charmingly prickish personality and habit of physically attacking those who disagree with him.  So, I explained to him as politely as I could (while maintaining a safe distance) that this was not something that we ever did and that he needed to speak to his doctor if he felt he should be on it. He threatened me and used enough profanity to make someone from the Sopranos blush, and then left the ER.

He was so angry at so many people that he decided that enough was enough and he was going to die. He took an overdose of someone else’s Vicodin and Xanax and locked himself in his room at the house he was staying at.

An hour later, one of his house mates came to check on him because he was “unusually quiet”.  No answer and so he broke down the door only to find his “friend” lying facedown on the floor with two empty pill bottles near-by. He tried to wake him up and then called EMS. They arrived within 5 minutes – 5 minutes where no one was doing any CPR on this 37 year old man. He had to have been dead for at least 30 minutes before EMS even layed hands on him. They worked him for 15 minutes with nothing and brought him back to me.

In the ER, we worked him for another 20 minutes and just before I called time of death, wouldn’t you know it – his heart started beating again. I really don’t know what happened to him eventually, but how could a man who has been totally dead for at least 30 solid minutes to one hour get anything back is beyond me.

If it was some kid who had drowned in a pool and was given CPR by mom and then brought to us he would have been dead of course. Its the people that seem to be the most vile that survive. The ones that you hope make it are never the ones that do make it. Their stories are tragic. As for these people, I honestly believe that they are anaerobes like bacteria.

They seem to actually thrive when they don’t have oxygen or other elements essential to life for the rest of us. They fall off a building and the next day they are walking out of the hospital after they have drained the life out of everyone they have come into contact with – which may in fact be their secret. Maybe there is some truth to Vampires after all?

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Coping Skills Don’t Come in Pill Form

July 9, 2009
Just swallow

Just swallow

OK, I promise to write more often (thank you all for the kick). June and July are always mega-busy as everyone tries to go on vacation, and then you get a Dumass doctor fired and it just makes things that much harder on everyone.

One of the saddest commentaries on the modern world that I see on an all too regular basis is the absolute lack of coping skills in the growing generation. We had generation X and then Y, and I guess they’ll need to call this generation W for whiners. Too pampered while growing up that they have no idea how to manage their own problems after they very effectively create them.

Case in point. This past weekend, I had the unfortunate experience of seeing LT on three separate occasions for what he described as “anxiety or a panic attack”. LT was a promising college football recruit out of his competitive high school district. I have no doubt that he was getting his bum kissed all the way through high school and well into college until he blew out his knee.

He went to surgery for his ACL, but being that LT had always had others to take care of him, he ended up with an infected knee and a PIC line. The nurses in the ED came to know him well as he would often roll into the ER for his scheduled IV antibiotics after midnight while drunk and with a different girl on his arm. And things would only get worse …

Soon after, one of his girlfriends got pregnant and decided she didn’t want him in her, or the newborn boy’s, life. On one of his drunk escapades, he got into a fight with some guys on a street corner. For some reason though, he was the one arrested (they were all the same ethnicity by the way). Since his knee was no good now, he also lost his scholarship and with it, the stream of girls who had followed him around.

So now he had only one girl left and a growing list of problems. So poor LT thought he was going crazy and came to the ER. There he received an rx for Paxil and some Ativan to help him calm down. Little did I know that he would be back a short 10 hours later. He told the nurse that the doc he had seen earlier “hadn’t taken the time to talk to him”. He was surprised to see that it was still me though and quickly backtracked by saying that what he meant was that he hadn’t had enough time to fully explain his problems.

So, I listened patiently to him as he told his sob story. Afterward, I explained to him once again that he was not crazy but that he had several issues that he would need to address one at a time (just like the rest of us mere mortals). He didn’t seem to like my suggestion as that entailed actual effort on his part. I resisted the urge to ask him if his girlfriend wipes his butt for him as well.

The next day he showed up yet again, this time saying that he felt chest pain. I was obligated to do more of a work-up this time – which was completely negative 80 minutes and $5000 later. I had no desire to see him again in what remained of my ridiculously long shift and hit him with the B-52. When his mother, I mean girlfriend, came to pick him up he was already half-way to his “happy place”.

Thinking I was done, I actually rested. But less than 2 hours later the police showed up with an inmate who had swallowed shampoo and some toothpaste in a suicide attempt. I asked him why he had done that, and he said that he couldn’t handle being in jail anymore. He was put in jail 3 days earlier for DUI. I thought to myself, “you really don’t know what being uncomfortable is all about – yet.” Then I got out the gastric lavage.

I don’t think he had bargained on getting a garden hose put into his stomach without sedation. But he just couldn’t get it through his mind that he needed to find a way, other than medicine to “knock him out”, to cope with prison life. The whole “do the crime, do the time” thing just didn’t compute in his mind.

The future scares me.

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Hookin’ Up at Work (How to Get Fired)

June 20, 2009

office romance

I know I haven’t been updating the site recently, and I’m very sorry for that. I have a growing list of posts in my head, but I have been working too hard to get them down. Usually I don’t like to work this much, but I have had to pull several extra shifts because one of our docs got fired. Docs don’t get fired too much these days due to the whole supply-demand thing, but every now and again, some idiot takes it too far and becomes a statistic. This is his story.

Dr. Dumass, as I would like to call him, had a good thing going. Cush hospital, good position, great co-workers, and even a nice office. But apparently for Dr. Dumass, the nursing staff was a little too nice for him. Dr. Dumass was actually working on marriage #4 (I am not making this up) when he met Nurse S. Not only was this his fourth wife, but he had a litter of kids spread out all over the country from the last three. To quote Brad Pitt from Fight Club, “F$%#@* was setting up franchises“.

Nurse S was cute, pretty and they hit it off as friends from the start. She was having problems in her marriage and enjoyed talking to Dumass about her marital conflicts. He in turn would share with her his own marital problems with wives 1-4. They got closer and closer. 

Finally Dumass made a great suggestion, “Why not get divorced from our current spouses and get married to each other!”  I can only imagine that Nurse S was married to a drug addicted, alcoholic bridge troll with anger management issues, because I am not sure what exactly would be the attraction to a guy who has already blown through 4 wives and 10+ kids? Maybe she thought that she would be “the one“. Silly wabbit.

Things were moving along smoothly for our confused couple and they could hardly stay away from each other while at work. Either our darling little nurse would be in the docs documentation area or Dumass would be out at her nursing station whispering sweet nothings into her stethoscope. Just some advice for any of you readers involved in a similar relationship – you may think that no one notices, but in reality, everybody notices. Even the blind frequent flier behind curtain #2 knows about it because he overhears the gossip.

Before long, Dumass had already filed divorce papers and was waiting for wife #5 to-be to do the same, but that’s when trouble in ER paradise started. Nurse S comes in to work one morning and tells Dumass the hard news – she was having second thoughts. Suddenly, Dumass starts to have chest pain – you know the kind you get when you really want someone to feel sorry for you and give you that big hug you want so much and tell you everything’s going to be alright. But instead of calling in a replacement, Dumass decides to work himself up.

He goes and gets an EKG and Troponin heart enzyme done on himself. “Hmmm, looks like there might be some changes on this here EKG“, he says to himself. So he calls up the trusty cardiologist who tells him that he should get a stat echo. The echo ends up showing some wall abnormalities and is not conclusive (imagine that?). So the cardiologist tells him to high-tail it over to the cath lab. That’s when the proverbial crapola hits the fan.

Dumass tells Nurse S that he needs to get cathed … that indeed this might be their last moments together. The sappy soap opera romance is too much for her and she tells the charge nurse that she needs to clock out and take her dying beloved Dumass to the cath lab. There is no ER doc now and the chief of staff – a pathologist (autopsy doctor) – is called in to cover the ER. Must have been interesting for him to have his patients actually talk back to him.

At the end of it all, Dumass’s heart was perfectly fine – no blockages of any concern whatsoever. But folks over at admin weren’t exactly ready to throw the welcome back party for him. Instead they fired him for his Dumass behavior. He had taken this too far, and he put patient lives at risk. I actually thought he deserved an award for entertaining the hell out of the rest of us in the ER though, but decided I would keep that idea out of the suggestion box for now.

What lesson can we take from this story? I will quote a wonderful colleague of mine who once told me, “A doctor can be totally incompetent, but as long as patients like him, he will remain employed. But the moment he has sex with the wrong person or comes to work drunk or stoned, he’ll be fired in a heart-beat.” I guess Dr. Dumass can testify to this one.

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A Review of Showtime’s Nurse Jackie

June 15, 2009
She Does What we Only Wish We Could Do to Some of our Patients

She Does What we Only Wish We Could Do to Some Patients

I recently watched the pilot episode of Showtime’s new show, “Nurse Jackie”, with the night crew. Jackie, played by Edie Falco, snorts crushed vicodin, steals money to give to the poor, forges an organ donor’s card, has sex on the job with the pharmacist who supplies her with the vicodin and flushes an arrogant jerk’s ear down the toilet after some choice words – and that’s just in the first episode.

In many ways – sex and drama aside – Nurse Jackie is the quintessential “take-no-crap” ER nurse that has served as an experienced den mother of sorts to so many young doctors and nurses still finding their way in the medical field. I still work with , and learn from, nurses like that, who continue to enlighten me with their experience, wisdom and knowledge. And no, I didn’t grab their boob or have sex with them in the supply room.   

On one hand, I fear that people will actually believe that nurses behave this way and treat them with even less respect.  I guess we will just have to leave it to shows like ER and Hawthorne to teach people to respect and admire the amazing efforts that nurses make to brighten, save and enrich so many lives on a daily basis in hospitals and clinics throughout the world. It is a noble profession that is too often the unsung hero. But back to the show …

Although it does present a flawed character portrayal of nurses, it is kinda fun to see someone act out what we all sometimes wish we could do with at least some of our patients. She has a distorted sense of ethics that leads her to do what will in the end be the most benefit to society in her opinion, and other times just gives people what we all know they really deserve. Except maybe her poor husband, but maybe the reasons for that will play out later.

From a doc’s perspective, I thought the whole Heimlich scene was coldly amusing. I get a similar feeling when responding to “Is there a doctor on the plane?”, because you really are never on vacation as a medical professional. It is a blessing, and sometimes it can be a drag, but no doubt it is wonderful to always be able to impact people’s lives – although not always in such dramatic fashion.

The nurses who watched it with me – male and female – enjoyed the show and were looking forward to future episodes. It presents an entertaining contrast to shows like ER and Grey’s where political correctness sets a border around the characters. So many of us in medicine hold back what we really think of some of the pathetic excuses for humanity that we see on such a regular basis from the the drug seekers, the self-righteous and those who feel they have the “right” to put us down, the domestic abusers who beat on their spouses, all the way down to child abusers and those who have children when they have no intention of doing anything remotely resembling parenting or loving, etc. It might just provide an outlet for those of us who bite our tongue and “do the right thing” even when it would feel so good to tell these people what we really think.

What I really want to know though is why the pharmacist has a bedroom in the hospital?

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