Who’s Committing Who Here?

When we commit a psychiatric patient, the reasons for which we can do so are limited to someone being unable to care for themselves or someone being a threat to themselves or others. That determination must be made by a psychiatrist, physician, qualified examiner, or a clinical psychologist.

We have these forms that we must fill out on each patient that we commit. No one has a “master” copy, so the ratty old forms get copied over and over again. Over time they start to look like crap. All the little marks on the paper get reproduced and new ones get added, so eventually it ends up looking like a bird had diarrhea on the page. Then someone doesn’t put the page straight on the copy machine, parts of the page get cut off or skewed.

We finally updated our forms and replaced one of our raggedy old psychiatry commitment papers. I had to keep this old copy for posterity.

The commitment paper wasn’t centered on the copier and right margins got cut off. Reading the reasons that a person could be committed showed that some of the words had been cut off.

Reading further down to the bottom of the page, the effect of blindly copying pages over and over again gets humorous. I never had the guts to check the box in the lower right, but often thought about doing so just for kicks.

Anyone that knows me probably wouldn’t have given it a second thought.

I Got Gas

OK, this post has very little to do with medicine.

I don’t even remember how I got there, but I ended up on the Mother Jones web site (which publishes a great electronic magazine by the way) and was reading this article about “hypermilers” who are on a mission to get the best gas mileage possible. They coast around corners, roll to a stop instead of breaking, tailgate trucks in order to lower wind resistance (called “d-fas”), and take all the weight out of their vehicles before leaving on a trip. During a hypermiling competition, several of the competitors averaged more than 100 miles per gallon. The winner came in at 180 miles per gallon. We have a, shall I say, eccentric doc at work that is like this and swears he gets 90+ miles per gallon to and from work. He makes his kids push him out of the driveway so he can coast down the street and he drives 45 MPH on the highways.

I have a 50 mile drive to the hospital at which I moonlight. Most of it is highways. So I used a few hypermiling tricks to see if I could increase my gas mileage.
Instead of driving 70-75 MPH, I drove at 60 MPH. It took me an extra 15 minutes for each leg of the trip.
I didn’t leave the air conditioner off all of the time, but I only turned it on when I got warm.
I did the d-fas thing behind trucks. By the way, I heard that truckers hate it when cars do this.
My results: I went from 23.4 MPG round trip to 30.1 MPG round trip. Almost a 30% increase in gas mileage with just these few tricks.
As an added bonus, I got passed over in a speed trap that most certainly would have busted me if I was going my usual speed.

Then I had a “green” mind snap.
1. While driving back from work, I watched several big tractors mowing the lawn on the side of the road. Is there some reason that states need to be mow grass on the sides of the highways? Sure, maybe it looks a little nicer, but is it worth all the gas we burn?
2. When I got home, the mail carrier was just pulling away from our mailbox. Do we really need to have mail delivered 6 days a week? What if mail was only delivered Monday, Wednesday, and Friday? Are any letters that important? Think about all the gas we could save if the mail trucks and airplanes were buzzing around half as much.
3. I opened an e-mail on my computer and had to make reservations for another meeting in a few weeks. Wouldn’t it be just as effective to have meetings over the internet using any of multiple internet services such as DimDim.com, WebEx.com, GoToMeeting.com, or Yugma.com? No money spent on hotels, no time wasted traveling, no travel to and from the airport, and no air travel.

Anyone close with members of Congress feel free to forward this post on so I can get some Al Gore-like movie rights and retire early, will ya?

I’ll even cut you in on the royalties.

Picture credit here

There’s A Rift In The Force, Luke

What’s going on with medicine lately?

The Evil Empire of Congress and Medicare have officially screwed the elderly patients in this country. Even though the Bush administration instituted a temporary freeze on Medicare cuts, the freeze amounts to little more than rearranging the deck chairs on the Titanic. Sick baby boomers and other Medicare entitlees are going to sink the Rebellion. More demand and less physicians will leave many Americans with even less access to health care.

Medical transport ships are crashing left and right and left again.

Like Jedi knights getting picked off one by one in the Revenge of the Sith, some of the best medical bloggers in the business have left or are thinking about doing so. Within the past month, Graham, Panda Bear, Sid Schwab, and ER Nursey have called it quits. Hopefully MonkeyGirl is just in some kind of an evil force trance and won’t leave us, too.

Who knows - maybe those little teddy bear things with the spears and slingshots will come to the rescue.

Until then, need to get out my tin foil hat and think happy thoughts.

Think happy thoughts.

Think happy thoughts.

Let The Mayhem Begin

Medical studies prove it. Interns are more error prone during the first month of their first year in training. July 1 is the “changing of the guard,” so doctors and patients alike - be careful out there.

In honor of the graduating students and the residents graduating to their new PGY year, below is my version of a MasterCard commercial for the best story I heard about a new resident on an OB service. First a bit of an explanation.

When a woman is in labor, doctors will periodically do a gyne exam to determine how dilated the cervix has become. When the cervix is only 1 or 2 cm dilated (sometimes called “fingertip” dilated because all you can get in there is a fingertip), delivery usually isn’t imminent. As the cervix dilates, you can begin to feel the baby’s head (unless there is a breech presentation and you feel a foot or the baby’s buttocks). When the patient hits 8 or 9 cm, the patient usually starts feeling a need to push the baby out. Grab your catcher’s mitt, because the baby is coming. A little more information about cervical dilation in pregnancy is here.

Getting back to the story … mind you that this story is hearsay, but it comes from a friend of mine who worked as a secretary on an OB floor, so I consider her a pretty reliable source. I also did an internet search to make sure that I’m not perpetuating some urban legend and I couldn’t find anything. So here goes:

Medical school education: $240,000
Brand new white lab jacket with embroidered name: $37.50
Four pack of Red Bull to keep you up all night during your first call: $9.00
Obstetrical textbook to learn about the stages of labor: $219
Three one-minute cell phone calls to the chief resident to update him on the patient who is pushing but whose cervix remains “fingertip” dilated: $1.20
Spanish-English dictionary to find out why the patient keeps saying something sounding like “debo empujar” (”I have to push”) and keeps calling you “pendejo“: $16.95
Watching the OB nurse double check the patient’s cervix, flip out, and call for a STAT c-section because the patient’s cervix is fully dilated, the newborn is in a breech presentation, and you’ve been sticking your finger in the kid’s anus instead of the mom’s cervix for the past 30 minutes: priceless

Picture credit here

Medical Care Unaffordable Even With Insurance

According to an article in the June 26, 2008 Wall Street Journal, more and more Americans are delaying medical care because it costs too much.

More than 1 in 6 patients who have health insurance either delayed or went without medical care in 2007 while almost 40% of those without insurance delayed or went without medical care.

People delay or forgo care because the markups are huge, and the only way we can get “realistic” pricing is to purchase overpriced insurance.

The manner in which we pay for medical care in this country must fundamentally change.

1. There has to be transparency in pricing.
Consumers need to be able to compare costs for a free market to work. I just received the first bill for the surgery I had earlier this month. The total hospital costs (not including doctor charges) were just under $30,000. In the span of 24 hours, I received hospital care worth more than the amount of money many people take home in a year. But that isn’t what the hospital got paid.
After insurance discounts, the total paid to the hospital was $6,500. I’m sure that Medicare would pay even less for the same surgery done by the same surgeon.
In other words, I got an 80% discount for surgery just because I had medical insurance. Same thing with my radiological testing - about a 70% discount. Someone else with Medicare could get the surgery for free and the physician/hospital would get stiffed even more for their work.
Of course, if the hospitals would get smart and start charging reasonable prices to everyone, they wouldn’t have to fight with the insurance company middlemen. Offer financing like a car loan if you have to. Some money is better than no money at all.

2. People must stop expecting free health care.
The public generally doesn’t think anything about paying $70/month for cell phones. We don’t blink when we pay a mechanic $85/hour to fix our car. Plumbers charge us before they leave the office and they kick up their rate when they come out in an emergency. We know up front that if we go to see an attorney, we’ll pay a large hourly rate and may have to come up with a several thousand dollar retainer before the attorney will even talk to us.
But if someone saves our life in an emergency department or if someone fixes our mangled arm, a lot of times the care is just expected - because many times someone else is paying for it. If we walk into a physician’s office, many of us expect to pay a $20 co pay. That’s it. “Don’t know how much it costs, don’t care how much it costs, all I know is I’m not paying for it.” Maybe I’m paying a $50 copay for the ED - and even that’s too much. Oh, and if the care isn’t darn near perfect, that’s OK, because then you don’t have to pay an attorney to represent you - they’ll do so on a contingency for free.
Until people begin treating medical care like any other service that is provided to them, the problem won’t change. In fact, the problem will get worse. Fewer and fewer doctors will be willing to provide services for lesser and lesser payments. If anyone reading this got paid 10% less this year and was expected to be more productive at what they were doing, how many would look for another job?

3. Stop Using Insurance For Basic Health Care
Many people may not be paying for their medical care, but the third parties that do pay are paying out less and less, then pocketing the difference.
Our family’s insurance rates just went up again. Now we’re paying about $14,000 per year for health insurance with $1000 deductibles. I’m coming to the point that I am strongly considering switching to $10,000 deductibles, paying $2,000 per year, and putting the other $1,000 per month into a money market account. If our family needs the money to pay for health care, it’s there. If not, then we’re $10,000 per year ahead.
Let insurance be there for the truly major medical expenses like it is now for home insurance and auto insurance. This gets back to the discussion we had earlier about Tier IV medications. We are getting to the price point where people may take their chances without insurance and negotiate with medical providers directly. To me, that’s the way it should be.
Insurance should be there to prevent bankruptcy, not to pay for a storm window that was broken with a baseball or a flat tire. Use insurance as it was intended and let the free market prevail.

As more physicians retire early or leave medical practice, less physicians enter primary care, and the baby boomers hit retirement age, we’re heading for the perfect storm - too many patients with multiple medical problems and not enough physicians. Like I mentioned in a previous rant on Kevin’s blog, even if the practice of medicine was made more appealing, it will take 4 years of medical school and 3-5 years of residency before more physicians will be ready to treat patients. We’ll be behind the curve with disastrous results.

When enough people pay nothing for their medical care, that’s just what they’ll get in return. Of course, you won’t be told that you’ll get nothing. You’ll just have to wait so long to get the care that either you’ll get worse to the point that you need emergency care or you’ll just die while you wait. Covert rationing is a simple way to avoid paying for a product.

Quality care, quick care, free care - pick any two.

Will people see the value in medical care before it is too late?

Not keeping my hopes up.

Lawnmower Safety

Just like snowblowers can cause injuries during the winter months, lawnmowers can cause injuries during the summer months.

Lawn mower blades can travel at up to 200 miles per hour. Anything that the blade hits is going to be damaged. If you slip on wet grass and your foot goes under the mower, you’ll get injured. If you try to unclog a running mower and a blade hits your hand, you won’t have a hand any more.

When a lawnmower blade hits other objects, those objects can travel up to 200 miles per hour coming out of the lawnmower’s discharge chute and can cause damage to people, passing vehicles, or other property.

This unfortunate injury was caused when a dad unknowingly ran over a rock with a lawnmower. The blades hit the rock and the rock was thrown across a half acre yard and caught his poor little girl in the side of the head. She was incredibly brave in the emergency department.

A depressed skull fracture was present (CT scan findings not from her - our CT scanner was down at the time) and the child required urgent neurosurgery. Fortunately, she’s going to be OK.

In the words of the unforgettable Sgt. Phil Esterhaus from Hill Street Blues: Let’s be careful out there!

Here are some basic lawn mower safety tips:

- Wear protective clothing including goggles, long pants, and non-slip close toed shoes.
- Before mowing the lawn, take a quick survey of the yard to make sure there is nothing on the lawn that could be hit by the blades and be thrown.
- Don’t disable safety features on the lawnmower such as the chute guards.
- If there is a bag on the side of the mower, don’t mow without it.
- Many mower injuries occur when the mower flips over. Don’t go sideways across a slope where the mower could tip - only go up and down the slope.
- Be careful when re-fueling a warm engine.
- Don’t try to fix the mower while it’s running. Turn it off and undo the spark plug before you mess with it.
- Don’t let kids use mowers.

Here are some more lawnmower safety suggestions from:
The American Academy of Pediatrics
The Insurance Information Institute
The University of Arkansas
The University of Michigan (hack, cough)
I also found one web site asking anyone with injuries to contact them because “THE INJURIES ARE NOT YOUR FAULTI” No, it’s not a plaintiff attorney site. Well, it might be, but according to WhoIs.com, the site is registered to an insurance agency that does business in Massachusetts … but has a mailing address in Texas … that is also shared by an engineering firm.

Why Buy Medications?

Found an article in Men’s Health Magazine from another article on MSN.com about how foods can improve anything from feeling sad to increasing metabolism, to helping out a hangover, to getting “in the mood.” Not sure how much faith I put in all the recommendations, but I’ll have to read more later.
Right now I’m going out to get Mrs. WhiteCoat a big box of dark chocolates.

Glad I Keep A Second Set Of Underwear

I got a chain e-mail from a friend. One of the things it stated was that to save money, when a patient is diagnosed with an arrhythmia, instead of cardioverting them, they will now drag the patients across a wool carpet and touch their fingers to a doorknob.

That chuckle reminded me of one of my patients from a time long ago ….

There was a good reason for his episodes of passing out.

While waiting for tests to come back, he slumped over on the bed. At first we thought he was kidding. Then we looked at the monitor (you’ll have to click the rhythm strip to get the full view):

First there were a few muffled gasps, then someone who shall go unnamed yelled “Oh SHIT!,” jumped over a desk, and ran to the patient’s bedside.

For those of you not accustomed to reading EKGs, this shows a patient going from normal sinus rhythm into ventricular tachycardia - probably due to the “R on T phenomenon.” That’s bad.

As quickly as it had started, suddenly the person accustomed to yelling shouted “CLEAR,” the patient’s body jerked, the smell of burning chest hair permeated the room, and he was back in the land of the living:

Amazing what a little electricity can do.

As an aside - while there may be some studies suggesting that thumping the chest with one’s fist can terminate an arrhythmia, I have never seen it happen.
Thumping the chest does make a cool “thumping sound” that echoes through the room. It also makes the person doing the thump look like they know what they are doing and makes other people watching the code pray that they don’t go into an arrhythmia so they don’t get thumped, too.

Second Opinions Over The Internet

USA Today published an article today about how more than 10,000 patients have obtained second opinions from online experts using a service called Partners Online Specialty Consultations.

Apparently patients pay $500 to $1500 by credit card, send their medical records by mail/fax/e-mail, and receive a second opinion online in about 2 weeks. The Clevenand Clinic and Johns Hopkins are also involved in similar endeavors.

For now, the cost comes out of your pocket. The article states that Cigna insurance is actually going to start paying for selected second opinions offered over the internet.

Online pharmacies are getting blasted for prescribing medications without actually examining patients.

The AMA has a position statement about online medical consultations. Among the AMA’s recommendations are that the consultations be provided “to patients that have an established relationship with the doctor or the practice.” The AMA specifically does not support online consultations between medical practitioners and patients where no established relationship exists — unless there is “no practical alternative or where they are employed to access medical care services in areas where such services may otherwise be unavailable.”

I consider these online second opinions the practice of medicine. You can’t get around that fact. You’re reviewing patient data and making a patient-specific medical recommendation for treatment. Since the patient isn’t physically at the physician’s clinic, shouldn’t the physicians providing these second opinions be licensed in the state in which the patient is residing?

Here’s another problem: how would malpractice laws apply to these consultations? If a physician in Maryland evaluates medical records online, gives the wrong opinion about a patient in Missouri, and the patient dies because of it, where is the lawsuit filed? Won’t the agencies that broker the deals between the patient and the consultants be on the hook for negligent referrals as well?

The USA Today article quotes the director of the eCleveland Clinic as saying that “in about 5% of the cases, we actually change the diagnosis of the patient. In 85% to 90% of the cases, we alter the treatment.” Are all the physicians that don’t practice in Ivory Towers really that bad? Or are these services making questionable/inconsequential recommendations so that they can give the public the idea that the second opinions are in their best interests and so they can make the patients feel like they’re getting something for their $1500?

There’s a medical saying that “the last physician is always the smartest physician” and these consults look like they’re trying to take advantage of that position.

The medical community must come to a consensus about the mechanics of providing these services - e.g. fees, licensing, malpractice issues, ethicality - sooner rather than later. We also have to reconcile why it is OK to provide medical opinions over the internet, many of which may include altering a patient’s medications, but why it is frowned upon to actually prescribe those same medications to a patient over the internet.

I can’t help wondering whether the current requirements for National Provider Identifier numbers are just a precursor to having a national medical license and making these online consults ubiquitous. It’s already happening with radiology.

Picture credit here

WhiteCoat Challenge Winners

The entries for this second WhiteCoat Challenge were all excellent, and I sincerely thank everyone for participating.

The contest sponsor has chosen the following two entries as winners:

Jeffsher63 is the winner of a new pediatric stethoscope for the following entry:

I’m a RN in a Pediatric clinic, and if I have to give a kid a shot, I get a 60cc syringe and attach a 3 inch spinal needle. When I walk into the room (I will usually do this to a kid that’s 8 years or up), his jaw usually drops, his eyes widen, and I oftentimes get some interesting verbal responses. I will usually let the child in on the joke shortly after they see the syringe, and they are usually relieved to see the much-smaller 3cc syringe with the 1″ or less needle. 99% of the time, the parent gets a good laugh out of it.

EEJ is the winner of the cardiology stethoscope for this entry:

The doctor asks my friend to drop his pants for an “inspection”, and as soon as he drops his pants and stands back up, the doctor reaches over and knocks on the door, which he follows up with an immediate “Come in!”.

Nothing like having your pants around your ankles and hearing someone else get invited into the room….

First runner up prize of a pair of red scrubs from my recent Scrubby Award (thanks to RedScrubs for the honor) goes to Reba for this entry:

My son was having his circumcision at 3 days old…the doc asked my husband to drop his pants so she could make my son look exactly like him…with a wide eyed look at me and a red face my husband began undoing his pants! The doc had to stop him between roaring snorts from me, the nurse and the doc!

Please contact me at whitecoatrants -at- gmail -dot- com so I can arrange to have your prizes sent to you.

All the entries were great!

In the end everyone was a winner because every medical professional who reads through the responses to this post will be able to walk away with something they can use to break the ice and make their patients a little more comfortable.

Many thanks to everyone for participating and another shout out to Boardman Medical Supply Company for its generosity in providing two high quality stethoscopes as prizes. If you need any medical or pharmaceutical supplies, Boardman’s is a click away. Just check out the link on my left sidebar.