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Dec. 28th, 2010

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Beagle

We said good bye to Bella the beagle yesterday. It was one of the hardest things I've ever had to do. I'll write more about it soon but for now will leave this poem I found.

Dogs Don't Have Souls, Do They?

I remember bringing you home. You were so small and cuddly with your tiny paws and soft fur.
You bounced around the room with eyes flashing and ears flopping.
Once in a while, you'd let out a little yelp just to let me know this was your territory.
Making a mess of the house and chewing on everything in sight became a passion, and when I scolded you, you just put your head down and looked up at me with those innocent eyes, as if to say, "I'm sorry, but I'll do it again as soon as you're not watching."
As you got older, you protected me by looking out the window and barking at everyone who walked by.
When I had a tough day at work, you would be waiting for me with your tail wagging just to say, "Welcome home. I missed you. "You never had a bad day, and I could always count on you to be there for me.
When I sat down to read the paper and watch TV, you would hop on my lap, looking for attention. You never asked for anything more than for me to pat your head so you could go to sleep with your head over my leg.
As you got older, you moved around more slowly. Then, one day, old age finally took its toll, and you couldn't stand on those wobbly legs anymore. I knelt down and patted you lying there, trying to make you young again. You just looked up at me as if to say you were old and tired and that after all these years of not asking for anything, you had to ask me for one last favor. With tears in my eyes, I drove you one last time to the vet. One last time, you were lying next to me.
For some strange reason, you were able to stand up in the animal hospital, perhaps it was your sense of pride.
As the vet led you away, you stopped for an instant, turned your head and looked at me as if to say, "Thank you for taking care of me.

I thought, "No... thank you for taking care of me."

By Chuck Wells

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Nov. 8th, 2010

Idiot

The problem with autonomy

Real story.

The other night an 18 year old young lady comes into my emergency department with diabetes. She's bad about taking her insulin and as a result her presenting blood sugar is over 700. What people don't realize about diabetes is that the problem isn't blood sugar. The problem is a lack of insulin. Because there's no insulin, you can't metabolize glucose, you can't make use of the fuel running through your arteries. As a result, your body is forced to find alternative energy sources. Generally this results in the liver producing ketones and acid. The resulting build up of these products can cause severe bodily damage over a short period of time, and as the glucose gets higher and higher, it sucks water out of the brain.

To put it to numbers, your body narrowly maintains a pH of 7.4 in the bood. It buffers the blood by producing bicarbonate, which makes the blood resistant to pH changes, even if acid or base is added. Most of us learned in chemistry that a pH of 7.0 is neutral, and is the pH of water, but for the body, a pH of 7.0 represents a significant build up of acid, overwhelming the body's ability to get rid or buffer it. Normal bicarbonate hangs around 24 or so. This girl's pH was 7.0 and her bicarbonate was 5. Under other circumstances, these numbers aren't compatible with life for very long.

The treatment for diabetic ketoacidosis is simple on paper. You give the patient what they don't have: insulin. You also supplement fluid (water for all intents and purposes) generously. When they are this sick, they are often vomiting, breathing fast and hard and complain of headaches and thirst. Unfortunately you have to control very tightly how much fluid they take in. Overhydration can cause serious and permanent brain damage. It's a fine line to walk.

So my patient, newly turned 18 and believing herself to be invincible, hasn't taken her insulin for several days. Who knows why. She comes in very sick and we start her on insulin and IV fluids. She gets upset that I can't let her eat or drink during this recovery process. In fact she gets so mad at me that she rips out her IVs and wants to leave. She knows where she is, she knows how to take insulin at home. She recites the date, the time, her location. Mentally, though a little slow from her illness, she's with it. But she's still my responsibility.

Do I let her go, or do I attempt to strip her of her rights and keep her? If she doesn't receive careful treatment, there's a very good chance she will die. I've seen it happen. These diabetics are SICK.

She storms around the department, threatening to call the police. I offer her transfer to another facility for treatment. She refuses. I offer to call her endocrinologist. She doesn't want to speak to him. I even offer her ice chips to suck on until it's safe to eat again. Not good enough. I try to get her mother to calm her down. No luck. I'm an idiot, I'm a jerk, I'm incompetent.

I could be charged with assault if I force treatment on her and she's declared mentally competent. On the other hand, if I send her home and she dies, her family can sue me for allowing her to depart. Can someone with a pH of 7.0 actually make sound decisions? This is the problem in this country, and my biggest problem with malpractice. Patients in American want 'autonomy;' they want to make all the decisions. But they don't want to take the responsibility for them, and we as physicians are blamed for the outcome.

I quickly called my charge nurser and my partner to assess the situation. We decide that she can't be declared mentally incompetent. In general, I don't believe that people should have treatment forced on them. If you want to go home and take the risk of dying, that's your perogative. If we as a medical community start stripping people of their decision making capabilities, then patients are in trouble. Still, I can't shake that fear of retaliation. What if her family hires a lawyer who says she should never have been allowed home?

I remember an OB friend of mine who recommended a c section to a patient struggling with a long labor and signs of fetal distress. Over and over again the patient refused because it wasn't in her birth plan. The baby had a shoulder dystocia and some neurological complications that likely could have been prevented by c section. The woman successfully sued because she stated she 'wasn't fully aware' of the consequences.

In the end I printed out a sheet of paper from Microsoft Word. It said, in bolded, 18 point font "I understand I could die." I made her sign it. I made her verbalize this understanding in front of my staff. I documented everything I could remember.

I still don't know if she's alive or not. I worry about her as my patient, but I also worry about retaliation. Because that's the system we live in. Someone else might have called a judge and held her. I believe that would have been a violation of her rights. There was little time to make this decision, but I had the agreement of everyone in the ED. Hopefully she is alive and well. Hopefully she took her insulin at home and recovered. But some part of me is still worried that my patient is dead in a ditch, and that she's there because I allowed her to go home when she was sick. Because I couldn't convince her to accept treatment, for whatever reason.

Remember this when you wonder why your physician won't just do whatever you want, no matter how much Googling you do about your illness. We are held to a standard of care regardless of what you want. And even if you say you accept the risks, we are still liable. Allowing you to do whatever you want still places us in danger of losing our lisence, of paying out millions of dollars. We want to take the best care of you as possible, and we worry. Even if you hate us, we worry about you. We have autonomy too, and we have medical opinions based on years of training and experience instead of Google.

Looking back, I honestly don't think it would have been right to detain her and strip her of her rights. But still I worry.

May. 14th, 2010

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Welcome

Charlotte Lily Northrop, 6# 14 oz born tonight at 1847. Everyone doing very well.

It was indescribable. More later.

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Apr. 6th, 2010

Lucifer

EMTALA and Immigration

Last post on EMTALA (I think).

A big concern during this health care debate has been what to do about illegal immigrants. It's a reasonable concern considering that we're trying to cut costs and move to a more publically funded system. Who should have access and who should pay the bill?

I can say that from my experience in Virginia, where we see a lot of Mexican workers (and I'm pretty sure many are illegal), that these people are generally the most grateful for their care of any demographic. They are not entitled. Dad and mom often come to appointments together. They say thank you and seem to believe what you tell them. I don't mind using an interpreter through our special 'blue phone' system (although it's pretty expensive to do so). It's a nice change from the poor white trash and inner city African American populations that I see who are rude, demanding, and always threatening to sue. Moreover, these people generally want to make some form of payment. I've been given tequila bottles, wine, cards, that sort of thing.

On the other hand, this scenario varies by state. Some of my friends in Texas and Arizona who see this population in much greater numbers have a much less favorable view. The accusation is that they use the system without ever contributing to it (i.e by taxes). By law if you have a child on American soil, the child is then eligible for medicaid/sCHIP (state children's health insurance program) even if the parent is not. Again, they ask the question of who should pay for care and how, especially if it's their own tax dollars going towards the care.

Under EMTALA, none of these patients can be turned away, no matter what, adult or child. Emergency departments must examine, evaluate and treat any condition deemed to be emergent. So if you come in with kidney failure, we've got to get you on dialysis.

Many argue that no money should be spent to get these people insurance. The problem with that approach is that the same government has entitled them to care. Much like the uninsured with a tragic event, the hospital will end up eating the bill. By denying illegal immigrants insurance, you are actually punishing the hospital (and I would argue the health care system as a whole), and not the patients.

I'll give you another example, not related to immigration. Many insurance companies will refuse coverage if you are drunk driving. The goal is to punish you for being stupid, and it's true that your credit can be ruined and that you will be responsible for the bill. But ultimately, the hospital simply won't be paid for the work they do. As a result, many EDs have decided not to do alcohol testing after accidents. If you don't look, the insurance company can't refuse to pay.

But what's important is that these situations (both the immigration and drunk driving issues) have come about as a desire to punish people for being bad. It's a moral judgement. Yes, I think if you're a drunk driver you should be punished. However it is completely inappropriate to use the medical system and bills as a bludgeon. We need to separate the legal and judicial system from the medical system in our heads.

I personally don't have a solution here. I very much enjoy taking care of my immigrant population, but I also can understand the concern about where the money should come from. Some have argued for manditory reporting laws, meaning that if someone comes into the ED for care and you are suspicious they may be illegal, then we as health care providers would have to call the authorities. I don't like that approach. My job should be to take care of people, not police the border. The current solution has been to not cover them at all, but as I've described, it's the hospitals and physicians who actually pay, not the patients. Not that the government, Democrat or Republican, really cares about that.

Mar. 25th, 2010

Head

individual mandate and EMTALA

I have a simple question for anyone who believes that it's 'wrong' or 'unconstitutional' to be forced to have insurance. What should happen to someone who opts out of insurance (voluntarily) and then has a catestrophic event such as a car accident? This question simply MUST be answered, yet I never seem to be able to get a straight answer or even an aknowledgement of the problem here. I'll tell you what currently hapens.

Right now, it doesn't matter whether you have insurance in the short run. Paramedics (publically funded) will scoop you off of the street and take you to the nearest emergency room, hopefully a trauma center, without even looking at whether you are insured. Once there, the hospital is obligated to stabilize and treat you due to EMTALA. If you need surgery, you'll get it. If you need several pints of blood, you'll get it. Your subsequent ICU stay could cost $10,000 per day, maybe more. Even once you're out of the ICU you will likely need weeks of rehab and inpatient management. Your total bill before the end cold easily be several miillion dollars. And then you're going to need home services and rehab, not to mention that you may lose your job and income or even your ability to generate income if your injuries are severe enough. Nonetheless, if you have chosen to opt out of insurance, there will be social workers who will try to enroll you for public programs such as Medicaid, though of course that's not always possible.

Let's say that you make a quick recovery and your bill only amounts to a measely million dollars, or even half a million dollars. What is your payment plan, since you've opted out of insurance? As I noted in my last post, EMTALA is a completely unfunded mandate. That means that the government has said 'you can't turn anyone away' but then the government refused to find a way to pay for it. The burden of payment is on the patient and the responsibility to collect it falls on the hospital. I know of very few people who could afford a medical bill like the one I outlined. Ultimately hospitals end up eating many of these bills. Even after going to collections, destroying the patient's credit and sometimes taking their assets, most of that medical bill will simply not be paid. Every year, hospitals give away literally billions of dollars in medical care. It's not free; the price is the patient's financial life and assets. But in the end, the care given is eaten and is money lost. If this scenario happens too often, a hospital will be forced to close (this has happened in the past).

So again, I ask: if you willingly opt out of insurance, what should happen to you (and I realize that not everyone voluntarily opts out)? Since you are clearly a responsible citizen, you wouldn't expect your care to be provided for free would you? Should we leave you to die since you have decided not to take part in the health system? My understanding is that private fire departments took a similar tack before public departments took over. You paid a contracted amount, and in return got a medallion or sticker on your home. If you had a house fire and had the sticker, they put the fire out. If not, well, too bad.

I have a hard time seeing how you can have it both ways. If you want to opt out of the system entirely, that's fine by me. Then don't expect me to resuscitate you when you come to my emergency department. Your choice should be clear. I suspect that you want me to do everything I can however and deal with the billing however. In that case, suck it up and get some insurance.

No one who's whining about the individual mandate has adequately even addressed this question. If any of you can enlighten me, please do!

Mar. 8th, 2010

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EMTALA

A number of people have asked me to comment on EMTALA as an emergency medicine physician. It occurred to me that few people know what this law is, how it affects people (both patients and physicians), or why it is controversial. So here’s some information about the laws under which hospital emergency departments must operate. Hopefully this will also shed some light on why physicians in general are suspicious when politicians get involved with healthcare.

The Emergency Medical Treatment and Labor Act was enacted in 1986, and continues to be controversial. That controversy can be seen in the statute’s characterizations by its proponents as the “anti patient dumping law” and by its detractors as “the law that grants free healthcare in the United States.” I’ll start by defining what EMTALA is, then get to how it affects patients, providers and healthcare as a whole.

Read more...Collapse )

Next up: Impacts and funding of EMTALA

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Nov. 15th, 2009

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Too close to home

My sister was just admitted to the ICU at West Penn Hospital with what we think is swine flu. The physicians there also noted bilateral pneumonias, and this morning she was electively intubated due to her deteriorating respiratory condition. It's likely that she initially got the flu, and now has a superinfection causing her other symptoms. Or she has ARDS from some sort of cytokine storm. Other than that, I don't know much, but needless to say I'm pretty worried. Kids are so resilient. It's easy to intubate a kid and get the tube out a few days later (generally if they're healthy to start with). Adults are a different ballgame, and I worry that she'll go downhill fast. Only time will tell. For all our technology, when it comes to intensive care, all we are really doing is supporting the body until it can heal itself. So now I have to wait and see.

My sister is about 14 years older than I am, but doesn't have any other systemic illnesses. Her only risk factor is her weight (BMI 36 or so), but that's turning out to be a big risk factor when it comes to lung capacity and weaning someone from a ventilator. She was not vaccinated.

Honestly I'm equally worried about my father, who has flown up from Florida to at least be in the area. He's 77 or so, and quite healthy, but according to my other sister doesn't look well (understandably). Hopefully this doesn't set off more rounds of atrial fibrillation or other cardiac event.
Time will tell. Sometimes it's difficult knowing too much, and sometimes you can know too little and too much at the same time. I'm not an adult doc after all.

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Sep. 12th, 2009

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Circumcisions and cost cutting

Since we’re talking about cutting costs, let’s talk about procedures. Giving Americans more input and more stake in their health care, making them pay for some things directly will likely go a long way towards reducing costs and reducing needless or frivolous testing. North Carolina Medicaid, as well as some other private insurance companies, has stopped paying for circumcisions. It’s considered a cosmetic surgery and therefore if parents want one done, they have to pay out of pocket. The NHS adopted this policy some time ago.

How good of a deal is a circumcision to the doc performing one? I don’t know national averages, but I asked one of the OBs here who performs them. My residency didn’t train us in circs and I’ve never wanted to learn, so I can’t and won’t do them. The OB told me that for this 15 minute procedure he makes about $115, and that he does maybe five circs in any given day if he’s on the delivery service. So for about an hour’s worth of work, he makes nearly $600 of pocket money. Not bad, right?

I propose that if we are so interested in cost cutting we drop coverage for circumcisions. There’s no point to getting them done, and parents that want them should pay for them. On average, there are about 11,000 births per day in the U.S. Assuming that half of those births are males (not entirely accurate, but go with it), that makes 5,500 males born daily. At $115 per circumcision, this procedure costs us $632,500 per day or $230,862,500 per year (again, assuming that all males are circumcised, which they aren’t). That’s probably a generous estimate, but I still posit that we could save a good deal of money. We’d also save money on management and repair of botched circumcisions (and I’ve seen a few) that get sent to the urologist to fix.

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Sep. 7th, 2009

Portrait

A Modest Proposal

If Congress or the president really wanted to do something to affect health care in this country, they could do so. The fact is our politicians overcomplicate absolutely everything, and then both parties overreact and miss the point. Now I've been pretty delinquent on keeping up my promise to analyze various issues of health care, so for now I'll just list four simple things that could be done to begin to address the health care dilemma. I'll flesh out these statements with more data and examples in the future. Change needs to happen, but you need to start somewhere and work towards a goal. I'm also fairly convinced at this point that accomplishing such change will involve dissolving at least 75% of the Republican Party. Seriously, they get scarier and scarier, spreading more and more lies, and I say that as someone who generally despises most of the Democratic Party as well. But I digress.

1. Address insurance companies directly. Introduce regulations that stop rescission of plans and stop the selling of shitty plans. Remember that 80% of medical bankruptcies involve people who already have insurance. Or thought they did. Make sure they cover everyone. I don't think making insurance companies non profit will sell, at least for now, and I don't think they have to be non profit in order to function properly. Nonetheless, the insurance market is designed to deny and refuse you care. They do this because we asked them to do it a long time ago and because the politicians don't have the collective balls to ration care in any way. Let the insurance companies make their own policies, but make them be honest about it and regulate them such that they must provide basic coverage to everyone.

2. Require everyone to get catastrophic insurance. For now, leave the primary care stuff out of pocket, it can be addressed later. If you're in an accident, get cancer, need dialysis, you're covered. Of the 45 million people or so who don't have insurance, many are young healthy adults without medical problems. Many of those people feel that buying insurance is silly because they're paying for something they don't need. Yet they would probably insist on being treated in an ED if they got hit by a car and were dying. Who should pay for that (and let me assure you that few can pay for it without insurance)? Moreover, if we're going to require insurance companies to cover you, they need to add people who are low risk. This is called risk pooling and counterbalances those sick people who will require payouts. If the government is going to provide catastrophic insurance, it will require taxes, and people in this country go bonkers over taxes. So let the newly regulated insurance companies pick this one up (prices can be regulated) for the most part, and then continue Medicaid as is.

3. Tort reform of some kind. This doesn't have to involve caps (in fact caps probably don't do much to discourage litigation or help those injured by negligence), but something has to be done to protect physicians more than they are, specifically in the ED (EMTALA laws) and OB settings. According to a report published by the American College of Emergency Physicians, “compared to the United Kingdom and Australia, the United States has 50 percent more medical liability claims filed per 1,000 people and a rate that is 350 percent higher than in Canada.” That's a problem, and every single country with universal access protects its physicians from litigation without sacrificing quality of care. Many physicians refuse to care for high risk patients due to fears of liability, especially in the ED, limiting access to good care (imagine going to the ED for a head bleed only to find out the neurosurgeon stopped covering there due to liability concerns). Protecting them would allow more people to have access to orthopedics and plastics when they need them. These reforms would also cut down on defensive medicine (estimated 25% of health spending) and reduce costs. What I hope is that providing everyone with care and insurance will reduce the incentive to sue. People not facing tons of medical bills may be less inclined to go to court. Maybe a publically funded 'no fault' law would work with specialized courts. Another idea is to prohibit trial attorneys from unprofessional advertising (The Hammer Stanley!), and prohibit them from going after physicians’ personal assets such as stocks and retirement plans. Oh, and shoot John Edwards in the jimmy for ridiculous cases like this one. Actually just shoot him no matter what.

4. Discuss end of life care. No, I don't mean death panels. We spend almost 20-30% of the health care budget on futile care. Examples include the 100 year old grandma with multiple strokes, and urosepsis who develops a bowel obstruction. A family will insist on surgery and full resuscitation even though grandma won't survive and physicians can't refuse. The other side (my side) is neonatal care. The 22 week premature infant who has anencephaly, yet the parents want 'everything' done. We spend millions of dollars torturing this poor child for a week before their bodies finally fail. The ones that do survive are so neurologically devastated they will have only a few years of high stress, expensive, poor quality life. America as a culture just doesn't believe in death; we believe in miracles for everyone ("have fun storming the castle!"). We need to get over it and get realistic, and physicians need support (both legal and media) in addressing end of life issues. Personally I've started inviting families in to watch as we do chest compressions and run the code. I put a senior EMT or tech with them to explain what we're doing. Seeing us pound on little Jason's chest and break his ribs trying to get his heart started really drives the point home. Please note that I'm not suggesting we stop resuscitating premies nor should we deny a relatively healthy 90 year old a life saving procedure. But we need to be realistic when things become futile.

I'll add to this discussion as a final point: Americans as whole will be forced to change the way they consume health care, which is a limited resource. Right now, people want everything done, and they want it now, without wait and without paying. On top of that we expect perfect outcomes. The UK and Canada have more realistic expectations. We are going to have to deal with the fact that there may sometimes be waiting lines or that taxes will have to go up to pay for some of this reform. Some out of pocket expenses are acceptable and probably good for people to give them a stake in their health. They are going to have to be willing to stop smoking and eating fast food and take some steps to improve their own health, using the resources which are already there. Until the public comes to terms with these things, then blame and responsibility cannot rest solely on physicians and politicians or even insurance companies.

Next post will likely be on EMTALA, unless you’d rather hear about billing and reimbursement.

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Aug. 8th, 2009

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Wikipedia wonders

How's this for scary? I was researching misinformation about vomiting and diarrhea (basically gastroenteritis) because there's a lot out there. If you didn't know, the old BRAT (bananas, rice, apple sause and tea) diet which used to be common knowledge was shown to have absolutely no benefit. The current recommendations are to resume a normal diet. WebMD had it wrong, and Wikipedia had it right, including the source cited. I'm impressed.

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