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“No one ever got well in a waiting room.” The growing trend of hospitals posting emergency department wait times online and via text message is nice for business, but [...]]]> WhiteCoat back with more news from around the web. See more at my blog over at EP Monthly if you’re dying for more.

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“No one ever got well in a waiting room.” The growing trend of hospitals posting emergency department wait times online and via text message is nice for business, but it also contributes to rising health care costs. “They encourage some people to use the emergency room when a less expensive option would be more appropriate, such as a doctor’s office or urgent care center.”
Another source aimed at hospital administrators thinks that catching the “post-your-waiting-time” wave is good for business.
Part of me wonders what’s going to happen the first time that someone sues a hospital because they went to a hospital advertising a shorter wait time then didn’t receive timely care.

Kind of like Burger King opposing building another McDonalds … One hospital system wants to build a new emergency department, another hospital opposes it doing so. If a hospital wants to invest assets in creating more facilities, let them.

Still playing hot-potato with the Grady dialysis patients. No one wants to pay for their costly treatment. Grady Hospital closed 96 patients out of its dialysis center in October 2009 and told them to go to another state, get care at an emergency room, or return to their homelands. Since then, there have been contracts with some private providers to provide dialysis, but it appears that those services will soon end. Many are now expected to go to the emergency departments for care.

Check out this funny account of an emergency department visit from Mother.

Medical care at USC-LA County Medical Center getting harder to find. Overcrowding in emergency department is now “dangerous” 8 hours per day. During a recent inspection, one post operative brain surgery patient who was brought by ambulance after passing out waited for 15 hours to be medically screened. The County is crying poverty. “We have no money. We have no financial resources to expand our services in order to meet this growing demand.”
When taxpayers don’t pay their bills, governments seize and sell their assets. Anyone ever looked at what kind of assets LA County has?

Of [...]]]> I’m not a pediatric endocrinologist but it seems to me that when someone calls that their kid with Type I Diabetes is puking his head off with  blood sugars of 400+ probably needs more treatment than just “give him some pedialyte  and see how he does”.   But hey, I’m just an ER doc, what do I know?!?!?

Of couse he continued puking and getting worse and more dehydrated.  By the time he came in, his BS was 490 with a PH of 7.1 and a Bicarb of 8.

Hello Peds ICU…..

Me:  “Ma’am, we need you to give a stool sample”

Pt: “What!  That’s disgusting!  I ain’t gonna sh** in a cup!”

Me: “Well, you can go in this bed pan and then scoop some out with the  included spoon in the collection set”

Pt’s Husband (holding a bucket of Popeye’s chicken and laughing at her): [...]]]>  

Me:  “Ma’am, we need you to give a stool sample”

Pt: “What!  That’s disgusting!  I ain’t gonna sh** in a cup!”

Me: “Well, you can go in this bed pan and then scoop some out with the  included spoon in the collection set”

Pt’s Husband (holding a bucket of Popeye’s chicken and laughing at her): “HA HA!  You gotta go crap in a cup!  HA HA!”

Pt: “You shut your face or I’ll give my stool sample in that Goddam chicken bucket!”

Me: “Lets not do that”

The answer to Friday’s quiz is….

Air in the Cavernous Sinuses. (see the areas circled in red and around them)

How did it get there? Well, when the EMS people put the IV in and gave him fluids and Zofran, somehow some air got into the line and was injected into the vein.  The air rises [...]]]>

The answer to Friday’s quiz is….

Air in the Cavernous Sinuses. (see the areas circled in red and around them)

How did it get there? Well, when the EMS people put the IV in and gave him fluids and Zofran, somehow some air got into the line and was injected into the vein.  The air rises so it went straight up to the brain where it is seen in the Cavernous Sinus (in the veins that run there).

Basically there is no treatment for this except that you have to make sure it goes away – and that it hopefully does not travel back to the heart and get shot out the arterial system and cause a stroke or infarct somewhere.

He stayed overnight and got a repeat CT the next day which showed resolution of it and he was fine.  The reason he came in was vertigo, the reason he was admitted was due to a “medical error”.  We had a conversation about the whole thing and the patient understood and seemed happy I gave him the low down on it.

]]> http://erstories.net/archives/2586/feed 14 http://erstories.net/archives/2574 http://erstories.net/archives/2574#comments Sat, 28 Aug 2010 11:04:45 +0000 ERP http://erstories.net/?p=2574 People often do anything to get out of work.  Faking illness, faking injuries, sabotaging something, calling in bomb threats, you name it.

The other day we had a fire alarm go off at night.  99% of the time it is a false alarm or a test of the system.  This time as I was talking to a [...]]]> People often do anything to get out of work.  Faking illness, faking injuries, sabotaging something, calling in bomb threats, you name it.

The other day we had a fire alarm go off at night.  99% of the time it is a false alarm or a test of the system.  This time as I was talking to a patient, we both smelled something burning!

Wow!  A real fire?  How can that be?  It seemed like it was coming through the vents in the ceiling so I went out into the dept to see what was going on. The smell got stronger and I followed my nose around the corner to the break room.  There in the room was a nurse trying to fan away smoke from a smouldering piece of chicken she was pulling from the microwave.  The whole place was smoke filled – no wonder the alarm went off.

Of course when the alarm goes off like that in a hospital, the troops come running.  Within 5 minutes a cadre of full-clad firemen with axes, oxygen tanks, and picks showed up ready to save the day.

We promptly paraded the microwave-challenged nurse (3 minutes for a piece of chicken?!?!) in front of them as the chief suspect in the ensuing arson investigation.   God, I know the weekend evening shifts suck, but come on, trying to burn down the hospital is a little impulsive.

Obviously we were kidding but she is gonna get razzed on this one for a while…

BTW, I will post the answer to yesterday’s CT question tomorrow.

OK, this one is pretty subtle – and I imagine only a radiologist or a neurologist (no pressure Dr Grumpy) will see the abnormality on this head CT.

History is that it is a 60 year old male with extensive cardiac history who called EMS because of severe sudden onset vertigo, nausea and vomiting.

He got IV fluids [...]]]>  

OK, this one is pretty subtle – and I imagine only a radiologist or a neurologist (no pressure Dr Grumpy) will see the abnormality on this head CT.

History is that it is a 60 year old male with extensive cardiac history who called EMS because of severe sudden onset vertigo, nausea and vomiting.

He got IV fluids and Zofran by paramedics and Meclizine by me and felt better.

He got the CT because he was on Coumadin and was a serious vasculopath (very bad vessels with a propensity for heart attacks and strokes, etc).

What we found required him to be admitted for a while despite his feeling better.

So, what is the finding, what caused it, and what do you do about it?

Bounty hunter trying to take patient into custody gets stymied by emergency department charge nurse. Too bad, Dawg. Bounty hunter then calls police who show up in the ED. Charge nurse gets [...]]]> WhiteCoat here with another health care update. See more health care news from around the net over at my blog over at EP Monthly Magazine.

Bounty hunter trying to take patient into custody gets stymied by emergency department charge nurse. Too bad, Dawg. Bounty hunter then calls police who show up in the ED. Charge nurse gets threatened with obstruction of justice.

Good thing there’s no snow on the ground. Sledding injuries cause more than 20,000 ED visits per year. Studies of ED visits between 1997 and 2007 showed that 26% of the injuries were fractures, 34% of the injuries involved the head, injuries to boys beat out injuries to girls by a 3:2 margin, 4.1% of all emergency department visits required hospitalization.

Fewer concerns about fibromyalgia patients getting raped on a date. FDA panel rejects application to use GHB – a “date rape” drug – to treat fibromyalgia. After seeing this article, I had to look up the indications for actually prescribing GHB – also called sodium oxybate. Pretty much limited to narcolepsy and cataplexy. Nothing more.

LA County pays out $5.5 million to patient diagnosed with brain bleeding, hospitalized for 5 days, released, and then who returned the following morning with massive brain damage, retardation and paralysis.

Speaking about LA County - the number of malpractice settlement payouts against the county dropped by 70% from 354 to 107 … but … the payouts increased by 50% from $8 million to $12 million.

Improving patient safety one corrective action plan at a time. Newborn baby accidentally given morphine. Heart rate drops and requires intubation. Later discharged in healthy condition.After the mixup was discovered, the hospital was fined $50,000 and had to come up with a “corrective action plan.”
The hospital’s plan to prevent things like this in the future? “Medications would no longer be administered in the neonatal intensive care unit.” Hope this is just a typo, but if not, patients at the hospital should hope their critically ill infant doesn’t have sepsis and need IV antibiotics or need blood pressure medication – under this “safety measure,” he won’t get them.

My day shift over the weekend gave me a host of wonderful “leftover” sign-outs.  The most notable of which was the lovely gentleman featured in the last two posts.  However, he was only one of the characters who spent the night before in drug-addled binges.

One man came in with “Crack Overdose” – [...]]]>  

My day shift over the weekend gave me a host of wonderful “leftover” sign-outs.  The most notable of which was the lovely gentleman featured in the last two posts.  However, he was only one of the characters who spent the night before in drug-addled binges.

One man came in with “Crack Overdose” – he did 500$ worth of crack in a short period of time and stated he “did not feel well”.  He had chest pain and palpitations and while waiting for my evaluation, the RN found him with the cardiac monitor leads wrapped around his neck like a garrote.   Hello psych consult.

Another man decided to smoke “an entire quarter” of weed and then pop about 6 Xanax.  He started acting “strange” according to companions and they brought him in.  He yelled at the PA who saw him claiming she had “invaded his house and dragged him in”.   It escalated to spitting followed by a nice big fat 10 of Haldol.

A young woman met a young man at a party. They decided to go home and have sexual relations.  The woman was brought in because she said “It was the best fu** I have had in a long time” but then she got sudden pelvic pain, stood up and passed out, striking her head on the floor.  The most amazing part of this is that the guy did not just yell “Peace out Sista!” and bolt. He actually brought her into the ER and stayed with her.  I guess he wants a second round next weekend.

Finally, a woman drank too much at a party and then when she awoke the next morning,while still in bed,  vomited all over her husband. He got annoyed concerned and brought her in for a “bad hangover”.

Can’t wait til next weekend!!

RN (to the man in the post from yesterday):  “Awww, come on! Look at the mess you made!”

Patient (in 10/10 affected lisping feminine voice): “YOU sound like a party-pooper!  Here, have some more!!!”

Pt procedes to roll onto his side, spread is buttocks apart, and expel faeces all over the bed and floor

RN: “OK, there [...]]]>  

RN (to the man in the post from yesterday):  “Awww, come on! Look at the mess you made!”

Patient (in 10/10 affected lisping feminine voice): “YOU sound like a party-pooper!  Here, have some more!!!”

Pt procedes to roll onto his side, spread is buttocks apart, and expel faeces all over the bed and floor

RN: “OK, there are some paper towels right there. You can start cleaning that up now please”.

For some reason, if I were to organise a sex party, I might specifically try to exclude a known [...]]]> When one is planning an orgy, the most important part is the guest list.  Obviously you want hot people.  People with clean bills of health. And people with good bodily hygiene.   Most sane people would agree on this.

For some reason, if I were to organise a sex party, I might specifically try to exclude a known HIV+ man (on no meds for it nonetheless) with rotting teeth who shoots up Meth and is  incontinent of stool.  I don’t know, call me bigoted but I just don’t want that guy there.

Evidently some other people welcomed this guy to their orgy – basically a late 70’s-early 80’s bacchanal of gay men going at it with each other fueled by drugs.  Unfortunately for this guy (and the other guests), he did too much Meth (he only shoots it he says because he doesn’t want it to “wreck his lungs”)after giving himself the pre-receptive intercourse enema and someone called EMS for his agitation and bizarre behaviour.  By the time he got here he was defaecating all over himself. 

Man, there goes the life of the party!

So, anyone that has gone to a rave (Nurse K,  I think you are a prolific rave-goer) knows that many people there (lets call them “ravieurs”) get their kicks out of more than just monotonous, thumping, melody-less, techno and house music.   They do tons – o – drugs!  Yeah, there is old-school stuff like [...]]]>

So, anyone that has gone to a rave (Nurse K,  I think you are a prolific rave-goer) knows that many people there (lets call them “ravieurs”) get their kicks out of more than just monotonous, thumping, melody-less, techno and house music.   They do tons – o – drugs!  Yeah, there is old-school stuff like weed and coke but the hippest people with a misguided sense of invulnerability take to things like GHB and Ketamine!   In fact, GHB makes you feel so relaxed it is a popular date rape drug as well!  We also use Ketamine to put people into a trance so they can get their fractures reduced and I have to say it works well for that.

So why not find some new uses for these awesome substances!  Well, some pharmaceutical companies are doing just that!  Ketamine has been found to be a “magic drug” when used for the treatment of depression.  Even more exciting, it that in addition to allowing one to have unconscious sex without recollection, GHB works great for fibromyalgieurs!

Honestly, of COURSE they work for conditions like this.  Psychiatric and pseudo-psychiatric conditions such as these respond to things that make you feel euphoric. What a surprise!  I think I am going to open a clinic. I will just dispense rx’s for GHB, Ketamine, and Marijuana.  Guess what, everyone that leaves my clinic will be happy!

Lets see how many OD’s of this we see once they are more available main-stream

I hate acute strokes. There are several reasons for it. Most of them are logistical. First, everyone gets into a tizzy because of the 3 (or 4.5) hour time limit after the onset of symptoms that which TPA can be given and hopefully improve the patient’s outcome. Unfortunately, this time limit (and [...]]]>

I hate acute strokes. There are several reasons for it. Most of them are logistical. First, everyone gets into a tizzy because of the 3 (or 4.5) hour time limit after the onset of symptoms that which TPA can be given and hopefully improve the patient’s outcome. Unfortunately, this time limit (and the data for TPA’s efficacy is only OK at best) causes mass chaos and annoyance.

First, one has to establish 100% what the exact time of onset was. This is NOT easy most of the time. I would say about 80% of “acute” strokes brought in by EMS turn out to not be within that window. It takes more than just saying “when did the symptoms start?”. Often the patient is elderly and demented. Often they live alone. Often there were milder symptoms before that were ignored or unrealised. Occasionally the person has hemi-neglect and can’t really say when things started. Sometimes there is ETOH on board. Sometimes the symptoms are on top of pre-existing stroke damage and it is hard to tell if it is really new or worse. Sometimes patients probably had a seizure at onset and that prevents them from getting TPA. All these things make history taking a royal pain in the ass. And remember, it must be done quick! The exam can be hard too. Sometimes the patient can’t reliably follow commands or there is a language barrier. Sometimes the patient’s preexisting abnormal findings make it hard to tell if something is old or not. Sometimes the person is so out of it the whole thing is a waste of time.

Second, once you are sure it is a stroke, you have to hustle. If the person came in within one hour, no prob. But if 2 have passed (or 3.5 in a younger patient eligible for the 4.5 hour window), it is tough. The bloods have to be sent off. BP may have to be corrected. You have to zoom the patient over to CT and get it read. You have to get consent (often from a family member who is on the telephone), as well as the WORST part of all. That would be calling the neurologist. Many hospitals (like mine) require that the giving of TPA is a two-doctor job – and one is the neurologist. I think mostly because neurologists are the best at making sure it really is a stoke. In many cases it is pretty obvious, but in the borderline, more challenging cases, they are much more astute than me at teasing out the minutiae from the history and subtle exam findings. This is important because TPA has a big risk; bleeding like stink. Turn a ischaemic stoke into a haemorrhagic one and you’ve screwed the patient royally. Cause a bleed in someone who really was not having a stoke? You are so screwed it is not even funny.

Anyway, calling the neurologist sucks. Why? The same reason it sucks for everyone else. They have to drop whatever it is they are doing and come flying in. As you can guess, strokes that happen at 2am are truly unwelcome. They hate to get awoken, and I hate to wake them. Even if it is during the day, they have to abandon their rounds or their patients in the office to come in. Of course I know it sucks (it wrecks my rhythm too) but part of me is just like “You guys did the research for this stuff and published the papers and made it standard of care!” . Regardless, one cannot explain how grumpy (maybe that is why Dr Grumpy is so grumpy) and unpleasant to deal with the neurologist is at 4am. If anything is out of place, if the flow of things is not perfectly smooth, or if the nurses don’t have everything ready for them, it’s freak-out time. And if GOD FORBID, the diagnosis is wrong! Or if they feel the symptoms started earlier and the patient is out of the window! Or if it turns out the patient has some contraindication to getting the drug! Lets just say the discussion between the doctors is not pleasant.

All this is bad enough but what really takes the cake is that the treatment is not very good! The data in the big studies blows (certainly compared to many other treatments for things we do). Even under the best of circumstances (which seem to almost never occur) the improvement the patient gets is only moderate (and even worse during the 3-4.5 hour window). Of course, that may be significant in the long run for the patient’s functioning but a good part of the time, they don’t improve at all! Add that in with the people who bleed and you have a treatment that few people are enthusiastic about. Of course this leads to another big suck-ass part, the giving or not giving of TPA in acute stroke is a HUGE lawsuit waiting to happen. If you give it and the person does poorly, you get sued. If you don’t give it and the person does worse, you get sued. It just SUCKS. So, I say PLEASE SOMEONE INVENT SOMETHING BETTER FOR STROKES!

Of course finally I hate it for what it does to patients. It can be truely devestating and the costs to the patient, family, and society is staggering.

Pt:” Yeah.”

Me: “OK, tell me about it.”

Pt: “It’s pure blood with clots and I felt lightheaded this morning.”

Me (thinking to myself “why the hell was that not mentioned on the triage note?”): “Oh my.  That is concerning.”

Pt: “Yeah, it [...]]]> Me: “OK sir, so the triage note says you have been vomiting but you have no other complaints?”

Pt:” Yeah.”

Me: “OK, tell me about it.”

Pt: “It’s pure blood with clots and I felt lightheaded this morning.”

Me (thinking to myself “why the hell was that not mentioned on the triage note?”): “Oh my.  That is concerning.”

Pt: “Yeah, it was pretty disgusting.”

Me:” Have you had any dark stools?”

Pt: “Yeah, It’s been black for about three days!”

Me (blood pressure rising): “Hmmmm.  Did you mention that to the triage RN?”

Pt: “No, I didn’t think much of it.”

Me (up-triaging the guy in my head): “OK, has this ever happened to you before? It says here you have no medical problems.”

Pt: “Yeah, once I had a tear in my esophagus.”

Me (up triaging some more): “Did you ever find out why this happened?”

Pt: “Well, a doctor told me about a year ago there was something wrong with my liver.”

Me: (up-triaging even more when I glanced at his monitor showing a HR of 105 and a BP of 98/56)):” What did the MD say was wrong?”

Pt: “He called it Cirrhosis.”

Me (leaning out of the room): “Nurse! Get me Octreotide 50mcg and Protonix 80, cross for 6 units, and start paging GI and the unit!”

Pt:  “Oh No!  Does that mean I’m really sick?!”

Me (rummaging through the IV cart looking for stuff to start an 18g) : “Well, it does raise some concerns…..”

22 Year old Patient: ” I don’t know, they said the nerves were damaged”

RN: “Well, did you have any injuries that caused it?”

Pt: “Well, I guess. I fell out [...]]]> RN:  “So, ma’am, you had a spinal fusion and had to cathertise yourself for a year?  You’re pretty young, and said you have no medical history.  What was the cause?”

22 Year old Patient: ” I don’t know, they said the nerves were damaged”

RN: “Well, did you have any injuries that caused it?”

Pt: “Well, I guess. I fell out of a third story window.”

RN: “Why didn’t you mention that before? Any other medical problems or history?”

Pt: “Six months later I got run over by a car and broke my leg”

RN: “Please don’t play the lottery, OK?”