Ewwww

I'll follow Shadowfax on this one. I've been saving these pics for a while, and I forgot about them. I was planning on starting a series of these, but I lost the battery charger for my camera. Grrr.

(clinical details redacted)

Before:



After:

Drug Seeking Scumbag

I have a question for my fellow docs, any pharmacists out there, or anyone else who knows what to do in this situation. Some scumbag has been calling in precriptions for Lortab and SOMA to numerous pharmacies around town while pretending to be me, using my DEA number. The guy uses various patient names, but for some reason he is using the same birthdate with each one (a pattern which has tipped off a couple of alert pharmacists).

One pharmacist told me she was going to call the DPS, another told me she would have him arrested if he came to pick up the prescriptions, but nearly every shift I come into work there is another message left for me by a concerned pharmacist with another occurrence. I literally have gotten a dozen such messages in the past couple of months.

I don't call in Lortab and SOMA to anyone, ever. Especially not 50 of each, with 3 refills.

Any suggestions?

Another Thank You Gift

This one from a satisfied but apologetic patient, with a note saying, "here's something to remember me by." I'm not sure if he was calling me a prick or suggesting that he was one, but it's funny as heck either way. Thanks, dude. Hope you feel better.

Big Time

Thanks to GruntDoc for the referral, Eric Berger, a writer for the Annals of Emergency Medicine kindly included an interview with me in his article on Emergency Medicine bloggers:

Inevitably most emergency medicine blogs include descriptions of patients. A doctor will present a case, and make a comment. Often the point is simply to vent—consider this snippet from a screed by the anonymous author of Scalpel or Sword for a patient who got tired of waiting and turned abusive:

“Oh, and yelling to the world that you have to go to work at 7:30 a.m. does not buy you any sympathy from the staff or your fellow patients. Are you suggesting that you are more important than these other folks, or that they don’t have to go to work? How insulting. Get your obnoxious (but uninjured) ass back in your room or leave. We don’t really have a preference.”

Such rants not only provide a release for a frustrated doctor, they can provide support and validation for hard, sometimes thankless, work. After posting that rant, the author received 13 supportive comments, such as “Wow! You DA man!” Such free, emotional releases are why a number of emergency physician bloggers, including the author of Scalpel or Sword, prefer anonymity.

“I would never want to embarrass my hospital, my patients, or my bosses, and I certainly wouldn’t want to lose my job over anything I might say,” said the Houston-based emergency physician. “So I change enough key details in each of my rants to provide a layer of camouflage to the average reader. Often cases I present are composites of several different patients or situations anyway. But they are all based on actual circumstances I have personally encountered. I don’t provide any personally identifiable medical information about any of my patients, so I avoid violating the strict HIPAA laws.”

I'm honored to be included amongst these fellow bloggers who I admire greatly, and who really inspired me to begin this hobby. Congratulations to GruntDoc, CharityDoc, Shadowfax, Trenchy, and Nick. I raise a virtual glass in a virtual toast to all of you, and to all of those who visit and comment here who make this so enjoyable for me.

Patient Decision-Making

The previous post stirred up a bit of controversy over informed consent, and whether the "unnecessary" tests I order are for my benefit or the patient's benefit. Ultimately, everything I do is for the patient's benefit. I would never order a test or perform a procedure that had no chance of helping a patient. But many of the tests and interventions I perform do benefit me, and I'm not going to feel bad about that. I go to work every night to benefit me and my family, and I'm blessed that I can earn a living while helping people at the same time. I can think of worse jobs.

Let's discuss a simple laceration repair, for example. Currently, we cannot bill for Dermabond closure of simple lacerations, even though many of the wounds that are able to be closed with this "superglue" could also be closed with sutures and wouldn't take much longer to do so. There is a certain amount of expertise required to skillfully close a wound with skin adhesive, but we cannot charge for the procedure, only for the ER visit. A one inch laceration that is closed with 4 or 5 sutures adds a couple of hundred bucks or more to my charges. Sometimes Dermabond is more appropriate or desirable than suture placement, for various reasons, and it would be inappropriate for me to not give patients that option, even though I stand to make less money. I have never once recommended a procedure only for my own benefit, when another procedure would suffice.

Another example is the chest pain workup. The undeniable fact is that chest pain is one of the complaints that can signify a life-threatening process, so the workup of patients with chest pain in the emergency department is invariably expensive and complicated. No matter what tests are ordered, the physician fee is going to approach $500, and the other charges are going to be expensive as well. And that's before the admission for stress testing, echocardiography, and telemetry observation.

If I see a patient who is unlikely to have a life-threatening cause of chest pain, I might be comfortable with just doing an ECG and a chest X-ray. Usually, lab tests are performed as well. Some patients are hesitant to undergo such an expensive workup, and are comfortable with limiting the number of tests that we do. Here is how I explain the process:

"You have chest pain, which may be as benign as a sprained ankle or as deadly serious as a heart attack. My clinical impression is that it is not serious, but I would recommend some tests to help sort things out. If we do no tests at all, you have a certain amount of risk. If we do an ECG, we can reduce the risk somewhat, and a chest X-ray will reduce the risk a bit more. Laboratory tests can give us more information, but ultimately none of those tests are sufficient to exclude a heart attack. Some people who come into the ER with heart attacks have all of those tests initially come back normal, and the injury isn't picked up until the next day. So we typically admit patients with chest pain to the hospital for observation and cardiac monitoring, and put them on the treadmill for a stress test in the morning.

Why do we do all of these tests? Because we really can't tell who is having a heart attack and who isn't when they come into the ER. I've discharged patients who have died before they even made it home, and I've admitted patients who I was sure were going to have heart disease who ultimately didn't. So my recommendation is to be cautious.

It's your decision.....what do you want to do? How safe do you want to be?"

My Personal Record

Most calls required to find an accepting physician: 13

This sequence began at 3am. My patient had a nasty fracture/dislocation of the wrist.

1) Ortho on call: "I don't do wrists. Call the Hand guy on call (Plastic Surgery)."

2) Hand Surgeon on Call, Dr. Lunate: "This is the answering service for Dr. Lunate. Please leave a message after the tone and your call will be returned."

3) 30 minutes later, no response. Left another message.

4) 30 minutes later, no response. I call him at home and leave a message on his answering machine.

5) Plastic Surgeon on call (but not for hands): "I don't do wrists. Sorry."

6) Plastic Surgery Resident: "I don't think Dr. Lunate is on the teaching service. But try this number...###-####."

7) ###-####: "This number is no longer in service."

8) Medical Director of the hospital: "You should call the Chief of Plastic Surgery. No, I don't know who that is."

9) Charge Nurse of the ER (I had to call her because she was in her office somewhere, not on the unit): "No, I don't know who the Chief of Plastic Surgery is, but I'll find out!"

10) Chief of Plastic Surgery, Dr. Beautaux: "I'm in New York for a Big Plastic Surgery Meeting. So are most of our Plastic Surgeons, in fact. It's a Really Big Meeting. Try the Chief of the Hand Service, Dr. Synovitis.

11) Plastic Surgeon who is covering for Dr. Synovitis (who is probably at the Really Big Meeting too, I suspect): "I don't do wrists, sorry. You might try Dr. Dikhed."

12) Dr. Dikhed, Plastic Surgeon: yells at me, because he is "not working this weekend!!!!!" (so why did you even answer your pager at 6 am?)

13) My last resort, Dr. Gohtew, with my favorite Orthopedic group (even though they are not on no-doc call), and who I really didn't want to abuse with this EMTALA special, but I was running out of options: "Well, I'll come down and look at it. If I can't fix it, I'll try to find someone who can." (YES!!!!!)

Then at 8 am, 5 hours after I made my first telephone call, Dr. Lunate (the hand surgeon on call) finally calls back and accepts the patient. I was so grateful to finally make the disposition that I never said a word to him about the delay.

The Cost of Defensive Medicine

A recent complaint letter involved the cost of a chest pain workup in a healthy young woman. She presented with a one week history of substernal chest pressure and shortness of breath that were worse both on exertion and inspiration. She was a cigarette smoker who took no medications and had no family history of heart disease or premature death. She denied cough, fever, or leg pain. Her vital signs and examination were unrevealing. She was basically just young and healthy.

After her ECG, chest X-ray, complete blood count, blood chemistries, and cardiac enzymes were reported as normal, I went back into the room and explained the rationale for CT scan of the chest (to rule out pulmonary embolism, primarily). She refused the test, and she was discharged against medical advice after I carefully documented our conversation, her awareness of the potential risks, and her acceptance of the risks of death or disability.

After receiving her medical bills, she was shocked at the charges and filed a complaint with the patient relations department of our hospital. As an uninsured patient, her bill for my level 5 evaluation and management charge was $500. The addition of the ER facility fee, laboratory studies, X rays, and Radiologist's professional fee brought the total bill to almost $4000 even without the CT scan of the chest (which would have probably added another $1500 or so to her tab, I imagine).

She also included the obligatory charges that I was rude to her and that I never performed a physical examination. I appreciated her suggestion that I take a remedial course on how to relate to patients. She claimed that she discussed her symptoms with a relative in Guatemala who is a physician, and he told her to take some ibuprofen, and of course she got better. Why didn't I think of that? Time for me to start looking for some CME, I suppose.

If I was a physician in Guatemala, I wouldn't have ordered any tests either, and I would have only charged her a couple of chickens, or maybe a young goat. In America, unfortunately, we are required to overcharge, overtest, and overdocument in order to keep the hyenas at bay.

Zero defect.... you nailed it, Uncle Panda.

Quotes of the Night

It was a tie:

First, the adorable octogenarian who when I lifted her gown to examine her belly, proclaimed:

"I don't have sex anymore."

Her daughters burst out laughing, and it was all I could do to keep a straight face.


And last, the long-haired, heavily tattooed dude with the exceedingly rare but supposedly quite painful genetic disease. He presented bearing a letter dated 10 years ago from an out of state physician who attested to his diagnosis. He claimed the letter referred to him, despite the fact that the surname was different. Mom was with him, backing up his story. He admitted to regularly using cocaine and purchasing Oxycontin off the street to ease the pain of his incurable condition, but yet he denied having a local physician who treated him.

"All you doctors think I'm just a drug abuser."

Two Americas

There are those of us who cut our own hair, there are many more who pay a nominal fee at Supercuts or some such chain, and there are those who take money from their campaign contributors to pay a Beverly Hills stylist $400 for a haircut. While sitting on a throne getting a pedicure, no doubt.

Is it still called a "haircut" if it costs $400? Or is there a fancier name for it? For that much money, he should have gotten a happy ending.

My New Hobby

As the latest mass casualty shooting proves once again, if you expect the police to save you from an armed attacker, you are living in a fantasy world. Police officers are useful for investigating the crime after someone is already dead or injured, but they cannot follow you around to protect you from an attack. Your personal protection is your own responsibility.

Even when law enforcement officers are on the scene of a violent crime in progress, their tactical protocols often delay them from moving in to assist the victim(s). Violent crime is on the rise, and it is not just crazed lone gunmen causing the trouble. It's a disturbing trend, particularly for those of us who often commute at night.

These are my latest two toys: on top, a Smith and Wesson Model 642 (.38 special +P) and on the bottom, a Kimber Stainless TLE II (.45 ACP). The little snubby (which is easily concealed in a pocket) has a Crimson Trace Laser grip which puts a red dot on the target, while the Kimber features glow in the dark night sights.

For storing the weapons (or other valuables) in the car, I recommend the affordable Center of Mass safes.

My favorite concealed handgun forum is the Combat Carry CCW Forum.

Applications for concealed handgun licenses in Texas can be submitted online at the Texas Department of Public Safety site. Texas laws regarding concealed handgun issues may be found there as well.

A variety of interesting targets and equipment may be found here. Not all gun ranges allow targets with faces on them, however.

My favorite (I shot this target with my .38 snubby at 10 yards):



The assault on the Virginia Tech campus is going to stir debate on both sides of the gun control issue. Obviously, my perspective is that if the campus had not prohibited their students from carrying legally registered concealed handguns, this attack could have potentially been stopped much sooner, and many lives might have been saved. But further restrictions on the sale or possession of weapons would not likely have been effective at preventing the tragedy.


picture credit: Oleg Volk

A Thankless Job

Mr. Santana is a 60 year old diabetic who had undergone an amputation of his right leg below the knee 6 months prior to our meeting. He presented for increasing pain, swelling, and foul smelling drainage from his left foot, and his toes were obviously beginning to become gangrenous.

"It looks to me like you are going to need another amputation at some point," I told him. "We can try some antibiotics and get the specialists together to see what we can do to make things better, but it doesn't look good."

He was none too happy about the prospect of losing his only remaining leg, and he acted like nobody had ever mentioned the possibility to him before. He looked at me with a combination of distrust and fear, like I was the devil.

As it turned out, he had just undergone an angioplasty of the arteries in this leg one week before, but we didn't have the records available. So I called the Cardiologist who did the procedure to see what his recommendations were. Fortunately, or not, he happened to be on call:

"Why are you calling me at 11 PM? I did my procedure and if it didn't work, then he needs to have an amputation. Thank you VERY MUCH for the FYI!!!!!!" He practically spat at me over the phone.

"Well, Dr. Ramakandathani, sorry to wake you up. I thought you might have another procedure you could perform, or maybe you wanted to recommend a specific surgeon. Mr. Santana seemed surprised when I mentioned the possibility of amputation."

"No. Admit him to the Medicine service. Goodnight."

As expected, the Internal Medicine physician on call was none to happy to get paged dumped on at 11 PM either, particularly since it was his 14th admission of the day and really more of a surgical patient anyway. But at least he wasn't sarcastic. He sounded more tired than angry.

Sigh. I can relate.

The Ultimate Threat!

Every part of the country probably has a colorful media personality who becomes locally well known for championing the rights of the disenfranchised underdogs in the community. In southeast Texas, we have the prototype: Marvin Zindler.

When all else fails, people here count on Marvin Zindler because they know he will cut through the red tape and overcome the frustrating obstacles preventing them from getting whatever it is they so desperately need. And the evil villains will soon get their comeuppance, guaranteed, or his name isn't Maaaaarvin Zindler.

So when a patient is discharged from the Emergency Department without a prescription for his drug of choice, or he is sent back to his lonely ramshackle trailer after being denied the weekend vacation hospital admission he had anticipated, nothing strikes fear into the hearts of the reckless uncaring ER staff like hearing the angry reject shout "Marvin Zindler is going to hear about this!" as he is escorted off the premises by our armed security staff.

It makes me tremble just to think about it.

Liar of the Year

Late night telephone call to the ER:

Caller: "Who is the doctor working tonight?"

Secretary: "We don't give out the physicians' schedules, sir. If you'd like to come in we'd be happy to evaluate you."

Caller: "OK, thanks."


Five minutes later:

Same caller: "Is Dr. Wonka working tonight? I saw her last week, and she told me to come back if I was having any more problems."

Secretary: "We don't give out the physicians' schedules, sir. If you'd like to come in we'd be happy to evaluate you."

Caller: "OK, thanks."


Five minutes later:

Same caller: "My 70 year old mother is having back pain. If I bring her in, will y'all be able to see her pretty quick?"

Secretary: "We don't give out waiting times, sir. But if you'd like to bring her in, we'd be happy to evaluate her."

Caller: "OK, Thanks."


Fifteen minutes later, the guy checks in complaining of back pain. I had seen his 70 year old mother one month before for her back pain, but this time her son was the one checking in, contradicting his phone call. I recognized them both, because he had accompanied her on the previous visit. I was suspicious at the time because she requested an unusually high dose of narcotics, and he did most of the talking. Plus my spidey sense was tingling. I documented my suspicions in the chart on their first visit, making this visit a no-brainer.

Me: "I'm sorry, sir, but I'm not going to be able to help you. I suspect that you are diverting narcotics, and I'm going to document my concerns in the chart. I'll be happy to write you some non-narcotic medications for your back pain, but neither I nor any of the physicians at this facility will likely ever prescribe either one of you any more narcotics ever again. Goodbye."


Two months later, they had the nerve to return when I was on duty, for the same complaint. I made them wait two hours in the room before giving them the boot this time. He acted like he didn't recognize me, and he denied that our previous interaction ever took place, even after I showed him the notes. You would think that a guy would never forget an ER doc who basically called him a lying criminal to his face and kicked him out of the ER without treatment, but he denied it all the way out the door. His only concern was that I made them wait so long before refusing narcotics this time.

Maybe he really didn't remember me; they have probably perfected their scam in emergency departments all over the country, and I must not have been the first one to figure it out. To them a denial of narcotics is just a temporary setback, no more concerning than a slow day at the office. There are plenty of other ERs out there, and they realize that it's difficult for caring physicians to refuse a kindly old woman "the only medicine that helps her pain." But sometimes, we should.

To all of the "real" chronic pain patients who come into the ER seeking comfort, this is why we cast a wary eye at you.

Meteor collision - averted!!!!!

This is a cute video. I consider global warming loonies to be just as histrionically ridiculous as meteor-fearers, btw. But this response to the meteor problem seems at least as likely as the Kyoto Treaty to save our planet from disaster. Technology > nature, right?

It's only a one minute video, so watch it. Even the most fervent and humorless doomsday scenario devotees will crack a smile. I promise.

Meanwhile, despite the impending doom of global warming, there was still snowfall at President Bush's ranch in Crawford, Texas yesterday. In April. Brrrr.

Guess I shouldn't have packed away my winter coat.

Liar of the Week

"I just can't take the pain anymore. I called my doctor and he told me to come to the ER."

This heavily tattooed scruffy young man had a history of multiple ER visits for a variety of painful yet clinically subtle conditions, so I was naturally suspicious.

"Where is your pain?" I asked.

"It's this hernia, doc. Right here."

"Hmmm. I don't really feel a hernia there. It seems more like a little lymph node in your groin." He did have a scar from a previous hernia operation, however.

"My doctor told me it was scar tissue pressing on a nerve. My extra strength vicodin isn't helping a bit. I'm scheduled for surgery in 2 weeks. It really hurts, doc."

"So who is your surgeon?"

"Dr. Madeitup, in a little town an hour away."

"So why did you come all the way up here? It seems to me like your surgeon would want to take a look for himself."

"I come up here every weekend. Besides, I like this hospital. Y'all have always treated me real good here."

"Well, I guess we should do a CT scan and see what's hurting so much. I'll try to contact your surgeon and discuss things with him too."

"He's out of town all week. Can I just get a shot for the pain? And a prescription for some sleeping pills? I can't sleep because of the pain."

"Maybe he's got his beeper on. I'll be back in a couple of minutes and we'll see what we can do for you."

"I'm just gonna leave. I've waited here long enough."

"Bye."

Pop

Slow motion video of knife bursting water balloon. Cool.

Play Ball!

Opening day starts today.