31 May 2010

Memorial Day


28 May 2010

Friday Flashback - Perverse Incentives

Byzantine \By*zan"tine\ (b[i^]*z[a^]n"t[i^]n),
a. Of or pertaining to Byzantium.
A highly intricate system characterized by bureaucratic overelaboration bordering on lunacy
c. Relating to medical billing processes

I recently reviewed a chart for a patient who had been in a car accident. It was an old man who had sustained multiple injuries and was seriously ill, admitted to the ICU with multiple consultants. I was struck by one feature of the chart -- the bill was absolutely huge. Far beyond what is typical for even a serious trauma.

There were the standard items:
Critical Care, 30-74 minutes, $596
Chest Tube, $574

So a pretty sizable bill just there -- $1100. But that was in fact the smaller part of the bill. The balance:
Fracture care: Shaft of clavicle, $489
Fracture care: Nasal bone, $79
Fracture care: Rib, $239 x 3 ribs fractured
Fracture care: Metacarpal bone, $490
Fracture care: Pelvis, $1157
Fracture care: Medial mallelous of ankle, $705
So, for fracture care, the total sum was a princely: $3600

Now I should point out that these are gross charges (gross, indeed!), and actual collection on these charges may vary from 90% (in a commercially insured case) to about 30% (Medicare) to 0% (no insurance). But even so, look at the disparity! The fracture care is more than triple the cost of the actual life-saving treatment this patient required.

Just to be clear, the patient had sustained a head injury (fortunately, a minor one), requiring CT scan of the head and neurosurgical consult. There was the chest injury requiring the ER doc to cut a hole in the chest wall to let out trapped air and release the pressure which was preventing the heart from filling with blood. Internal injuries in the abdomen required consultation with a general surgeon. And the patient was elderly and frail, with other medical conditions and was in shock. The ER doc spent over an hour on this case alone, and did a tremendous job pulling someone's grandfather through the "Golden Hour." It's a Medicare patient, so he'll probably get $300 for his efforts.

BUT, he put on a few splints, x-rayed the right body parts, and did a very careful dictation noting all the injuries. And for that, he'll get three to four times the remuneration he did for the hard, scary, critically important life-saving efforts.

So, for the health policy types:
The system is fundamentally and irredeemably broken. Fix it now.

For ER interns:
In order to compliantly bill for definitive care of a fracture in the ED you must be sure to document:

  • The name of the broken bone, the anatomic location of the fracture, and whether it was open or closed
  • What interventions you performed (i.e. reduction, splint, strap, analgesia, ice, etc)
  • Post-intervention assessment (i.e. neurovascular status, pain level)
  • Follow-up plan
In order for the ER doc to legitimately bill for this service, you must actually provide the same care which would have been provided by a specialist. If follow-up with a specialist is required (say, for cast placement), the reimbursement will probably be split, with the majority going to the initial physician.

Sheesh, no wonder the average salary of an orthopedic surgeon is twice that of an ER doc, which is itself half again that of a family practitioner.

Originally Posted 09 July 2007

27 May 2010

Vivid language

As a generalist ER doc, there are so many things that I have not done or do only occasionally.  When one of those things pops up, as they do almost every day, I have the good fortune to be able to call a specialist. If it's an item which is clearly outside of my competency, then they come in and take care of the problem.  More often, however, it's something which I am perfectly capable of doing, after reviewing the options and discussing the technique with the specialist. 

This is a nice situation to be in, since it saves the specialist the need to come in, reduces the delay in care for the patient, and allows me to learn and increase my own abilities.

But sometimes the advice I get is a little surprising, or at least couched in terms which most people would find disturbing.

For example, the other day I saw a 14-year old boy who was helping his father change a flat tire when the jack handle snapped up and hit him in the face.  One of his lower incisors (#23 for those of you keeping score at home) was avulsed.  He and his dad got into the ER within 30 minutes, and showed me the tooth.  It was intact, though it had been allowed to dry out.  We washed it in saline and threw it into a milk solution.  This is one of the few true dental emergencies: if the tooth is to be salvaged, it needs to be re-implanted within one hour.  The fact that it had been allowed to dry out greatly reduced the likelihood that it would be salvageable, but it was worth a try.  The only problem: I had never done this before, not in the thirteen years I've worked in an ER.  Intact tooth avulsions are just not that common.  Worse, on exam, all of his lower front teeth had been pushed back a bit and I couldn't even see the socket where the tooth must have come from.  I made a tentative effort to just slide it back in, to no avail.

So I called the oral surgeon.  There was no way he would be able to come in in time to fix it himself, but I wanted some advice.  This is what he told me: "At 14, his alveolar bone is still pliable.  So you need to do a really good dental block, find a likely-looking spot, and just cram that son of a bitch in as hard as you can.  Don't worry, it'll go.  I'll see him in the morning and properly fixate it."

Cram that son of a bitch in as hard as you can.  

Yeah, that made me cringe a little bit, too.  So I did.  Good anesthesia made it painless for the kid, and I picked a spot in the bloody mass of gum and shoved.  It took enough force that the kid's jaw was pushed down quite a bit, but then something gave with a crunch and the tooth slid right in like it was supposed to be there.  Which, I suppose, it was.  It seemed solid enough, and who knows if the thing will be viable, but we gave him the best possible chance.

Then the same evening, there was a nine-year old girl who fell off the monkey bars (or as orthopedists call them, the money bars).  She had a nasty fracture of her wrist:

Uploaded with plasq's Skitch!

I don't generally reduce these.  There is enough displacement as the bones over-ride (or "bayonet") that we usually call ortho in to fix them.  That's more a matter of practice style, though, and there's no reason why an ER doc can't reduce it.  I called my orthopod, who unfortunately was just going into a big case which would take him several hours.  He reviewed the film on line, and advised me that if they wanted to wait, he could do it much later in the evening, or I could just do it. I'm generally game, and asked if he had any tips.  "Sure," says he, "you need to put her under -- deeply -- and basically recreate the injury.  Don't be wimpy about it: you have to go medieval on her.  There'll be a nasty crunch as you complete the ulnar fracture; don't worry about that.  Make sure you have the parents sitting down or out of the room. But if you can bend the fracture site all the way back past ninety degrees, you can push it back onto the shaft and it should stay in place."

Hrm.  Go medieval on her.  That doesn't sound real pleasant, does it?

But I did.  It was actually just like doing tuite -- joint locks on the hand and wrist.  Got an absolutely beautiful reduction.  Her dad went a little green at the whole thing, but stayed conscious.  Truth be told I have seen this done innumerable times, so it wasn't exactly terra incognita to me.  But it was satisfying to do it myself for once.

And now, when I describe the procedures to my partners and trainees, I am sure to include the vivid language.  It really helps describe what you actually need to do to accomplish the technique.

Dismissed with prejudice

The sweetest words a doctor can hear from his malpractice defense attorney.

Just saying. No reason.

26 May 2010

An Idiom Come to Life

An idiom is a common expression that has acquired a meaning that differs from its literal meaning, such as “It's raining cats and dogs” or "kicked the bucket." Idioms can be very challenging for non-native speakers of a language to get their heads around, since there's often no relationship between the intent and the literal expression. My brother-in-law is an Israeli for whom English is his third language, and he and I have had many entertaining conversations about the colorful colloquialisms in the English language.

Recently, I was pretty upset about some clinical issue that was affecting care in the ER. I thought I might be over-reacting, which I am prone to from time to time, but I didn't want to back down from what I thought was an important matter. I went into our medical director's office and sat down. "OK, Larry," I began the conversation, "talk me off the ledge here..."

Which is a wonderful idiom, when you think about it. It's actually much more comprehensible than the "kicked the bucket" apocryphal sort, since it paints a vivid picture of a scenario familiar to anybody who has a passing familiarity with the "Lethal Weapon" movie series.

It became that much more ironic when, the next day, I was seeing a psychiatric patient in the ER. She was suicidal, but sort of chronically suicidal, the sort of depression-plus-personality-disorder patient who visits the ER more often than some staff but never actually does anything to harm herself.

As a digression, I have always thought that "personality disorder" is such a terrible diagnosis. I mean, if you're depressed or bipolar or whatever there are lots of hand-waving euphemisms such as "chemical imbalance" to allow patients to bolster their self-esteem and not feel like their illness is their fault. "Personality disorder" is so much worse -- it basically means that you're a fundamentally maladapted person and, so sorry, there's no pill we can give you that will fix that. How do you tactfully tell a patient something like that?

Anyway, this lady was a borderline personality type (all the medical professionals reading this just cringed) and she was driving us all nuts. Intermittently polite and charming alternated with shrieking and abusive behavior, and for a while she bought herself four-point restraints. No psych facility wanted to take her because they didn't see any benefit to hospitalization for this sort of chronic, not-serious suicidality. But she was demanding that we admit her somewhere, so we were kind of stuck.

Then she escaped.

This is not supposed to happen from the psych rooms in our ER. There's constant security presence and the doors lock. Obviously, somebody slipped up, which is easy enough to do when the patient is there for hours and hours. We didn't think she would be too difficult to find, though, since she had for some reason decided to strip naked before slipping out! Sure enough, she was spotted on the campus, running around, naked as a jaybird, and she let the police and security staff something of a merry chase before they finally corralled her in the parking garage.

But before they could cuff her, she ran up the stairs to the top of the garage. She climbed over the restraining barrier and out onto an I-beam which juts out about ten feet from the building, four stories up. There she stayed and refused to budge.

I have to complement the police on their management of this situation. They were consummate professionals in a difficult spot and they did manage to get her back in without her coming to any harm. She was returned to our department, wrapped in a thick blanket, wet and shivering. This time it was not difficult getting her placed at a psychiatric hospital.

At the end of my shift, I was dictating my charts. As I finished the dictation for this case, my partner who was coming on shift was sort of listening in as he did his paperwork. When I put down the phone, he turned to me and said, "I cannot tell you how jealous I am that you got to dictate in a medical record, the phrase 'talked off the ledge,' and it was literally true."

I agreed that it was remarkable, that sometimes the idioms really do come to life.

22 May 2010

I can't believe we ate all those samosas

My friend, who is Nepali, was supposed to have dinner with us today.  He always makes the best samosas.  But he had to cancel, sadly, and I was beside myself.  What was I to do without his lovely pastries?  I decided to make my own.  We invited over some friends as guinea pigs helpers, and set to it.  The result was shockingly yummy:
Uploaded with plasq's Skitch!

The recipe made 32 samosas.  We gave kid kids one each. The little bastards didn't touch theirs -- "I don't like those" was the refrain. That left 27 for us -- about 7 each.  We ate them all, along with a prodigious amount of basil chicken and naan.

Then I went to the kids' plates and ate theirs, too.  I am not proud of that, but it is what it is.

If you want to try your own, I highly recommend this recipe:
1 1/2 cups all-purpose flour
3/4 teaspoon salt
1 tablespoon ghee, clarified butter or vegetable oil, plus 1/4 cup, plus extra, for frying
6 to 8 tablespoons ice water
1 teaspoon ground coriander seeds
1/2 cup chopped yellow onions
2 teaspoons minced fresh ginger
2 teaspoons minced garlic
2 hot green chile peppers, minced
1 teaspoon garam masala
1 teaspoon salt
1/2 teaspoon turmeric
1/8 teaspoon cayenne
2 large baking potatoes, like russets, about 1 1/2 pounds, peeled, cut into 1/2-inch dice, and boiled until just tender
1/2 cup par-cooked and drained green peas
2 tablespoons chopped fresh cilantro leaves
2 teaspoons fresh lemon juice
To make the dough, sift the flour and salt into medium bowl. Add 1 tablespoon of the clarified butter and rub the mixture between the palms of your hands to evenly distribute, letting the fat-coated flour fall back into the bowl. Continue until the flour is evenly coated. Add 6 tablespoons of the water, mix, and work until the dough comes together. Turn onto a lightly floured surface and knead for 4 minutes into a firm dough. Cover with a kitchen towel and let rest for 30 minutes.

To make the filling, in a large saute pan or skillet, heat the remaining 1/4 cup of clarified butter over medium-high heat. Add the coriander seeds and cook, stirring, for 10 seconds. Add the onions and ginger, and cook, stirring, until starting to caramelize, about 5 minutes. Add the garlic, chile peppers, garam masala, salt, turmeric, and cayenne, and cook, stirring, until fragrant, 30 to 45 seconds. Add the potatoes and cook, stirring until the potatoes start to color and become dry, about 3 minutes. Add the peas and cook, stirring, for 1 minute. Remove from the heat and add the cilantro and lemon juice. Stir to combine, then adjust the seasoning, to taste. Let sit until cool enough to handle.

On a lightly floured surface, knead the dough for 1 minute. Divide into 2 equal portions and roll each into a 1/2-inch thick rope. Cut each into 8 equal parts and roll into smooth balls. Place each ball on the floured surface and roll into a thin circle, about 6-inches in diameter. Cut each circle in half (2 semi-circles). Spoon about 2 teaspoons of filling in the center of each semi-circle. Brush the edges with water and fold the dough over the filling. Press the edges together to seal. Place on a baking sheet and repeat with the remaining ingredients.

Preheat the oil in a large pot to 350 degrees F. Add the pastries in batches and cook at 300 degrees F, turning, until golden brown, about 10 minutes. Remove with a slotted spoon and drain on paper towels. Serve hot.

We went light on the chiles, which I now regret. I'm a wimp when it comes to spices, so I was hesitant, but the potatoes really attenuate the heat, so go for it. The cilantro and lemon also balance the spice too.

Frankly the best part of the whole process was dicing the fresh ginger. I don't know what that stuff does to your serotonin receptors, but it's pretty damn potent, whatever it is.


21 May 2010

Friday Flashback - The Weirdest Damn Thing I've Ever Seen

I will preface this with the obligatory disclaimer: I shit you not.

The complaint was "Visual hallucinations," and the patient was not exactly the sort of individual you would expect to be hallucinating. He was a middle-aged, affluent corporate executive, a sharp and high-functioning individual with no history of either substance abuse or mental illness. He was, therefore, rather perturbed by the little red and green elves he kept seeing all over the place. He knew they weren't real, but they just wouldn't go away. (We attributed the fact that they were red & green to the fact that this case occurred shortly after Christmas.)

My partner, "Bill," was a superb physician, but I would never let him take care of me in a million years. Not because his skills aren't good: they're excellent. He's one of the best doctors I have ever had the honor of working with. But Bill is what is known in the business as a "black cloud," or, less politely, a "shit magnet." Somehow he always manages to get the most awful, obscure, or just plain bizarre cases, and when he works, the crazies always come out in force. In fact, it was Bill who signed out this gem to me. So when he came to me with this case, perplexed and looking for advice, I was not particularly surprised. It seemed par for the course for him. The work-up in these cases is pretty straightforward and almost always unsatisfying: rule out medical causes and consult psychiatry. So Bill orders a slew of labs and a CT scan of the brain.

This is where it gets weird. Um, weirder. For some reason, Bill ordered a Troponin, which is a blood test marker of heart damage. I wouldn't have ordered it -- there's no logical connection between the heart and odd psychiatric symptoms. I would have probably confined my lab tests to electrolytes, blood sugar, a drug screen, that sort of thing. But Bill, conditioned by the strange stuff he sees, casts his net a bit wider. And the troponin came back strongly positive.

Which was completely unexpected. We had not even done an ECG. But when he saw the troponin, Bill immediately ordered one, and saw something like this:

Which was even more unexpected. The following amusing conversation with a cardiologist ensued:

"So I have a guy here having a heart attack with a positive ECG and troponin."

"Great. I'll be right in. Is he still having chest pain?"

"Well, that's the funny thing. He's never had any pain."

"Interesting. What was his presenting symptom?"

"Visual hallucinations. Elves. Christmas elves, we think."

"Bullshit. You are kidding me, right?"

But we faxed him the ECG, which was really quite convincing, and the cardiologist came in reluctantly, and somewhat dubiously took the patient to the cath lab. Sure enough, the patient had a high-grade obstruction of his LAD, and upon opening it, that patient's ECG returned to normal. The next morning on rounds, the patient thanked the cardiologist for saving his life, and ventured that he didn't want to seem ungrateful, but the elves were still bothering him, and could he please do something about that? Psychiatry saw the patient and concluded that he wasn't crazy. So the neurologist was called in and noticed an odd motor tic every time the patient looked at the elves, who were always sitting to his left. The neurologist speculated that the hallucinations might be a form of a partial complex seizure, so he started the patient on an IV drip of dilantin, an anti-seizure medicine.

And the Elves went away.

So there you have it: Acute Anterior Myocardial Infarction presenting with Partial Complex Seizures manifested as hallucinations of Christmas Elves.

And that, ladies and gentlemen, is the weirdest damn thing I have ever seen.

Originally Published 17 July 2007

19 May 2010

Why Cats Are Not Employed As Doctors

Why Cats Are Not Employed As Doctors
• Valuable minutes lost in surgery as doctor furiously paws at nearby fly.
• While informing patient's family of their loss, doctor suddenly loses interest and walks off.
• In bid to become chief surgeon, doctor scent-marks entire hospital.
• Doctor refuses to respond to own name during code blue.
• Staff grows increasingly alarmed as doctor runs up and down hallway for no apparent reason.
• Sensing colleagues' growing dissatisfaction with his work, doctor curls up against a radiator and goes to sleep.
• Doctor raises hackles and bares teeth whenever new interns are introduced.
• Doctor loses medical license after licking self, instruments clean.

So what have we learned? That cats are best employed in service industries? Certainly. But more importantly, always listen for meows when entering a hospital. The life you save may very well be your own.

(From Francesco Explains it all, but I do not know why)

18 May 2010

Curing Malaria with Fricking Lasers

This is way cool:

I'm skeptical it'll ever hit that mass deployment, but even if it doesn't whoa is it cool.

If you're not already listening to them, I highly recommend the TED talks as commute-worthy listening.

17 May 2010

Emergency Protections in the Affordable Care Act

There's just so much that is hidden and buried in the ACA that it's like an Easter Egg hunt trying to find all the goodies. Hopefully the surprises will all be good! ACEP News pointed out one hidden goodie, nicely illustrated in this article from Kaiser Health News:

Under the new health law, insurance companies must extend several new protections to patients who receive emergency care. One of the biggest guarantees: Patients who need emergency treatment will have their costs covered at the same rate, regardless of whether they are treated at "in-network" or "out-of-network" hospitals.

The law also bars health plans from requiring prior authorization for emergency services. And it mandates that plans follow the "prudent layperson" rule. For example, if a person goes to the ER with chest pain, but ends up being diagnosed with indigestion, the claim has to be covered because going to the hospital under those circumstances made sense.

The provisions go into effect for every health plan issued after Sept. 23 – six months after the law was enacted -- that offers emergency coverage.

This is potentially quite significant. As with so many things, the devil is in the details, and the implementation is not yet actualized.

The actual text of the provision is here, from Sec 2719 of the law as enrolled:
If a group health plan, or a health insurance issuer offering group or individual health insurance issuer, provides or covers any benefits with
respect to services in an emergency department of a hospital, the plan or issuer shall cover emergency services (as defined in paragraph (2)(B))-
(A) without the need for any prior authorization determination;
(B) whether the health care provider furnishing such services is a participating provider with respect to such services;
(C) in a manner so that, if such services are provided to a participant, beneficiary, or enrollee-
(i) by a nonparticipating health care provider with or without prior authorization; or
(ii)(I) such services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on
coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more
restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and
(II) if such services are provided out-of-network, the cost-sharing requirement (expressed as a copayment amount or coinsurance rate) is the same requirement that would apply if such services were provided in-network

It goes on to review the definition of the prudent layperson standard.

So why is this significant? First of all, it appears to close an annoying loophole in the Prudent Layperson statutes that states have passed. A long time ago in a legendary epoch called the nineteen-nineties, insurance complanies used to routinely deny claims from emergency departments, retrospectively, claiming that the diagnosis provided was not in fact an emergency and the patient should not have gone to the ER at all. This created an outcry and many (I think all) states responded by passing laws creating a "prudent layperson" standard which basically says that if a person had reason to think there were having a medical emergency and they went to the ER the insurer had to pay for the care. But the problem here was that these were state laws, not federal. Health insurance plans, particularly the ones purchased by large-ish employers, are usually organized under the federal ERISA statute. ERISA does not contain any prudent layperson language, and it pre-empties most state insurance regulations. What this means is that most group insurance policies are not bound by the prudent layperson standard.

Fun fact: I discovered this when I took a family member to the ER once and the claim was denied as "non-emergent use of the emergency department."

So, if I read the law here correctly, this sounds like it would extend the prudent layperson language to group plans organized under ERISA, which I think represents something like 60% of the group insurance market. I don't know that this is as important an issue as it once was, since most insurance companies don't do this sort of thing any more, but as I learned, some still do.

The other provision I admit I am unclear on how far it extends. The requirement that insurance plans cover emergency care at the same level of cost sharing regardless of whether it is in or out of network could be a minor tweak or could be a real game-changer.

The clear intent is that patients not be penalized for being brought to an nonparticipating provider when they have no choice (i.e. an emergency), So if your plan requires a 80/20 split for in network and a 60/40 split out of network, that would be moot as far as ER care goes. The plan could not impose more than a 20% cost-sharing regardless of network status.

But this is where the ambiguity is. It does not say what the 80/20 split is a percentage of. Say you are brought to the ER and the doctor's bill is $500. An in-network doc probably has a negotiated discount which might bring the cost down to, say, $300. So your 20% of that would require the consumer to pay $60 and the plan would pay $240. But an out-of-network doc does not have a discount agreed to from the insurer. If the insurer does what I expect, they will just apply the discount anyway (calling it their "allowable" charge) and pay the $240. In that case the doctor will then send a bill to the patient for the other $260, expecting payment in full.

I can see a few ways this could play out. Patients could appeal to the insurance commissioner, who could rule that the insurance company is unlawfully imposing a 52% cost sharing in patients who are out of network. In that case, the insurers would have to pay the full $400 and the patient would be responsible for their 20% -- or $100. Or the insurance commissioner could allow the plans to continue with their practice and the patients would be stuck with the rest of the charge. And in some states, including mine, the state has or is considering banning the practice of balance billing, which would force the doctor to accept the cram-down and eat the lost charges.

I will be very interested in seeing how this plays out nation-wide, but I can assure you that in my state once we get our lawyers to review this issue we will be requiting an opinion from our Insurance Commissioner to clarify how this will be implemented. It could really change the relationship between physicians and insurance companies and could substantially add to protections consumers receive from the unfair and unilateral business practices of the insurance companies.

16 May 2010

Nimoy Sunset Pie

The strangest damn thing I've ever seen.

Every single day I get down on my knees and thank the FSM for the wonder and glory that is the internet.

14 May 2010

Friday Flashback - That which does not kill me...

Only postpones the inevitable.

I spent a lot of time postponing the inevitable last night. It seemed like every patient was a severely demented octogenarian, non-verbal and non-ambulatory, either septic or with a lower extremity long-bone fracture. (Or, in some cases, both!) Blessedly, most came in with valid DNR papers, so I did not have to pursue heroic measures, but (as I have had to explain to several hospitalists) "Do Not Resuscitate" does not mean "Do Not Treat." So I went and tanked them up with fluids, cultured them from stem to stern, poured in gorilla-cillin and got the relevant consults, all the while shaking my head at the sheer futility of it all. It could have been worse -- the families were all either absent or present and realistic -- no frantic insistence upon unreasonable interventions. But it seems like even the most reasonable families still have a problem withholding antibiotics. They're down with the notion of "no life support" but "just let Granny die" seems too cold for them, especially when contrasted with the seemingly non-invasive IV fluids and antibiotics.

I was lucky, though, that admidst the wreckage there was one beautiful shiny satisfying "Emergency Medicine" case. As good as a Nursemaid's Elbow. Healthy, happy patient, grateful parents, ER doc looking like a hero.Yes, she swallowed a dime. No, she's going to be fine -- 99% of them pass within the week. If you like you can examine her stool, but realistically, you can do nothing at all as long as she has no symptoms. If you like you can follow up for a repeat x-ray at her pediatrician's office in a week, but even that is not necessary in the absence of symptoms.

That case put the smile on my face to get me through the rest of the shift.

Originally Published 25 June 2007

10 May 2010

The Patient Dump

There are times when you don't quite want to go see the next patient in the queue.  You scan the chief complaint and visit list, look around as if to say "aren't there any other doctors here who can take care of this for me?" And then, because it's your inescapable fate, you pick up the chart, square your shoulders, and walk into the room.

The patient was a young lady with pelvic pain.  She had moved up from Texas one month ago, and had already been to our ER six times for this complaint of pain.  She was a complex patient with a history of a gynecologic malignancy (reportedly -- nobody had ever been successful in getting records from Texas) and she suffered from pain related to this history.  Only Demerol worked to treat her pain (she had been quite shocked to learn that we don't use Demerol, but quickly adapted to Dilaudid instead).  She had not yet established care with a primary care doctor or a gynecologist. The imaging studies in our ER had been unremarkable.  So it appeared that she was here for pain medicine again with no change in her symptom complex.

These cases are challenging for an ER doc.  You can take the easy road and just give 'em some pain meds and send them away, but that more or less guarantees they will be back for more pain medicine.  Or you can take the hard road and send them away with nothing, but that can be really hard, and there's a risk you're undertreating someone with real pain, and they'll probably be back anyway and you'll get a complaint to boot.  There's no win here -- either way this is not a problem amenable to fixing in the ER.

But there was a twist with this young lady: she told me right up front that she had just been seen in the ER at St Mugworts Hospital, the suburban place directly to the north of our somewhat larger suburban place.  She'd been there before too, but this time, she said that they had told her that since she had been getting her care at our hospital, she needed to come back here so "her doctors" could take care of her.  As proof, she handed me the discharge instructions from Mugworts, slightly crinkled from her purse.  Sure enough, they were dated and timed about two hours ago, and they read "Go to The Big Hospital in (our town) for your gynecologic care."

I was pretty stunned by this.  I had never seen an ER doc so brazenly execute a patient dump.  I clarified with her that she did not have a doctor at our hospital, just the ER docs she had seen, and that she had informed the ER doc at Mugworts of that fact.  I couldn't resist -- I was so angry -- so I called the ER at Mugworts and asked to speak with Doctor Loser, who had sent her to us.  That was a fun conversation.  He must have been so pleased with himself at neatly getting a problem patient out of his ER, and he so clearly had not expected to be called on his little maneuver.  I was clear with him -- I asked him if he had obtained an accepting physician before transferring this patient to our hospital (this immediately informed him that it was an unfriendly conversation and carried a threat of an EMTALA violation).  He hemmed and hawed and said that he had just suggested that it was an option for the patient to go to Our Town.  I pointed out that his documentation had been fairly direct, and asked what capacity we had that his hospital did not, and he waved his hands (metaphorically speaking) about the patient possibly needing emergency gynecologic surgery and our doctors knowing her better, but I was having none of that -- I pointed out that she had told him that our GYN surgeons had not seen her, and that he should have consulted his gynecologists about this patient, if he thought she might need emergency surgery.  At this point, backed into a corner, the ER doc played on what he thought would be my sympathies, "Surely you agree that with chronic pain it's in the patient's best interest to be treated at a single facility."  True that.  No doubt.  Once the patient is in your ER, I countered, she is your responsibility.  You manage her pain, or you say no.  You don't ship her (without notice or consent) to a neighboring facility.

At this point, I had the poor bastard wriggling in my grasp.  I was not about to relent.  I was pissed.  "I am going to go take care of this patient now.  As you and I both know, she does not need emergency surgery.  She needs a pain management plan and I am going to work on one with her.  And I am going to give Dr Jones a call about this inappropriate patient transfer in the morning."  Dr Jones was the Chief of Staff at Mugworts; I happened to know him through legislative activity we had collaborated on before. 

And I did -- he was appalled.  What's more, at Dr Jones' suggestion, I wrote a very polite and carefully worded letter to the Mugworts Board of Directors.  I explained that "I strongly feel that it is inappropriate to “dump” such a patient, either expressly or with a nod and wink, onto a neighboring facility.  I believe that this episode would be considered with great concern by both state and federal regulators.  I believe that a case could be made that this was a clear violation of EMTALA.  Were I to report this to the relevant agencies, it would create significant administrative difficulties for St Mugworts Hospital and for Dr Loser.  I view our relationship with Mugworts as one of neighbors and partners.  It is therefore my hope that by providing you with this feedback, your Medical Quality Committee will have the opportunity to review the care provided, and take corrective action to prevent further inappropriate transfers between our facilities."

I am quite certain nothing "happened" as a result of this episode, by which I mean that Dr Loser is still working there and that he did not face sanctions or penalties as a result of his little trick.  Which is fine -- I wasn't trying to get him fired.  I suspect that he had to deal with some pretty unhappy emails and maybe explain himself at some administrative meeting, a painful experience.  Maybe he got a slap on the wrist -- a verbal rebuke and some fluff for the record.

What I am equally certain about is that there is one doctor at St Mugworts who is never again going to try to dump a patient on The Big Hospital without calling us first and getting an accepting physician.  Which is as it should be.

07 May 2010

Friday Flashback - Direct Admit?

Dear Mr Jones,

I writing you in response to your letter of the tenth. I understand that you do not feel that you should have to pay the ER doctor's bill for the treatment you received in the ER, since you were sent over to the ER from your doctor's office for a "direct admission."

However, it appears that there is some confusion over this point. If your doctor wanted you to be a "direct admission," he (or she) would have sent you to the hospital admitting office with orders to have you admitted under his or her own name, or under the care of the on-duty hospitalist. He did not, but rather sent you to the ER.

It is possible that he sent you to the ER because the on-duty hospitalist refused to accept you as a direct admission, feeling that you needed urgent assessment and stabilization treatment in the ER. Is is equally possible that your doctor sent you to the ER because it was the easiest way for him to get you off his back and pass the buck to another doctor. It is possible that he simply forgot how to arrange a "direct admission" because "just go to the ER" is a million times more common these days. We will never know because a review of the ER phone log reveals that he did not call with any instructions for the ER doctors regarding the expectations for your ER visit. Since you arrived to the ER after the close of office hours, your doctor was not available by phone to verify the plan, and the on-call clinic doctor did not know who you were.

A review of the ER record shows that you did receive a full history and physical exam, and that the ER doctor who saw you performed and interpreted multiple diagnostic tests, reviewed your medical records, treated you with intravenous medications, and consulted with specialists before making the independent decision to admit you to the hospital. We feel that the ER doctor's investment of time and effort (and risk) into your care justifies the charges applied to your account.

I know it does not feel like the ER doctor "did" anything because most of the work took place out of your sight, and because you had already told him that you were there to be admitted. However, most patients sent to the ER under similar circumstances in fact are sent home, either because they turn out to not have a medical problem requiring admission, or because their illness can be diagnosed in the ER and treated as an outpatient. So, in fact, the ER doctor did provide a valuable addition to your care.

We apologize for any annoyance or irritation you have suffered, and hope this writing finds you in good health. Please remit payment at your earliest convenience.


Shadowfax, MD

cc: Primary Care MD

(Addendum: In fairness, I often do reach the PCP by phone who informs me that he did not send the patient to the ER to be admitted, but to be assessed. Somehow patients reliably misinterpret being sent to the hospital as implicitly meaning 'for admission.")

Originally Published 27 June 2007

06 May 2010

England's Election Night

Don't really understand or care much, but it gives me a chance to post this popular Monty Python clip:

It's a funny thing how little election coverage has changed since 1970, from the multiple pundits commenting rapid-fire, the breathless "breaking" news and the silly gimmick -- in this case the swingometer, as opposed to CNN's holographic correspondents.