Quote of the Century

"The real issue is this, who would you rather have in charge of the defense of the United States of America, a group of people who never served a day overseas in their life, or a guy who served his country honorably and has three Purple Hearts and a Silver Star on the battlefields of Vietnam?"

- Dr. Howard Dean (Democrat) 2004
Physician and current chairman of the Democratic National Committee




John McCain has been awarded the Silver Star, the Legion of Merit, two Bronze Star Medals, a Purple Heart and the Distinguished Flying Cross.

(h/t Hot Air)






Hillary Clinton was awarded the German Media Prize, the United Arab Emirates Health Foundation Prize, and she was once named Arkansas Woman of the Year.







Barack Obama has won two Grammy Awards for Best Spoken Word Album.

Make That Diagnosis

Maybe this will become a series, like the ones over at NY Emergency Medicine. If you win, you get a cookie.

Or, like with White Coat Rants' "You Play Doctor," perhaps not.

A middle-aged woman is brought to the ER by her doting husband, complaining of chest pain. It's her fifth visit of the year so far. Previous workups during those visits have included 3 rapid influenza screens, 2 CT scans of the brain, 1 CT scan of the chest, several X-rays, and multiple series of blood tests, including cardiac enzymes and liver panels... all of which were entirely normal. And yet her pain was so severe that she required repetitive doses of Dilaudid. Her pain was never really relieved, she was just made sleepy enough to not protest too much when she was discharged each time.

Although her chief complaint is "chest pain," as the interview progresses it becomes clear that she really hurts all over. Her headache is intolerable, her chest feels like it is being torn apart, her back is aching horribly, and she claims that she is too weak to get out of bed. She says that she has been vomiting for days, and she "can't keep anything down."

She's dressed in a nightgown and robe at 2 pm, and other than her depressed affect and subjective generalized weakness her examination is pretty unremarkable. Her vital signs are normal, her mucous membranes are moist, and her abdomen is surprisingly nontender. She never actually vomits in the ER, she just feels nauseated and refuses to drink water. Her husband comes up to the nurses' station and asks "aren't you going to do anything about her pain?"

Her diagnosis is probably:

1) Lupus
2) Porphyria
3) Lyme disease
4) Churg-Strauss syndrome
5) Polymyalgia Rheumatica
6) Migraine
7) Fibromyalgia
8) None of the above

Her workup for this visit should include:

1) Repeat CT scans of the brain and chest, and maybe the abdomen.
2) Forget the CT scans, let's do some MRIs.
3) Repeat the comprehensive lab panel, and let's add a lyme titer, lupus panel, and urine for porphyrins.
4) spinal tap
5) Psych consult
6) Admission for further workup and pain control
7) None of the above

I lied about the cookie, by the way. There are no winners in this scenario.

Quote of the Week

"The last time that I checked, a nipple was not a dangerous weapon."

The Wave of the Future

The wave of the future is the free-standing Emergency Department.

By requiring insurance coverage or full payment at time of presentation, these facilities are able to offer reduced waiting times, concierge-style amenities, and a full array of emergency diagnostic and therapeutic services. And if they refuse to accept Medicare or Medicaid, then they are not forced to follow the restrictive rules of EMTALA.

EMTALA applies only to "participating hospitals" -- i.e., to hospitals which have entered into "provider agreements" under which they will accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program for services provided to beneficiaries of that program.

So these "free-market" emergency facilities can not only refuse treatment of patients who are unwilling or unable to pay, but they can also transfer patients at will without negotiating with a receiving hospital or jumping through a lot of regulatory hoops. Realistically, however, hospitals love receiving transfers from these types of facilities because they know they are getting fully-paying patients. Do you think that a hospital might accept an otherwise healthy well-insured young woman with a gallstone attack in transfer, perhaps causing the cirrhotic Medicaid patient to wait a few more hours in their own ER? I think they just might. The bottom line is a powerful incentive.

As this business model becomes more widespread, hospital-based emergency departments will be faced with an increasingly problematic payer mix, because the higher-paying patients will be siphoned off the top, leaving only the most undesirable trauma and Medicare/Medicaid populations to fill their overcrowded waiting rooms. And when emergency physicians have a broader selection of practice environments to choose from, I suspect the hospital-based ERs will soon have some difficulty filling their schedules as well, thereby compounding their problems even further.

Guess what?

Healthcare isn't a right after all.

Thanks to KevinMD for the link!
And David Catron nails it.

Time/On the Run

Classic Posts

I've been pretty lackadaisical while fighting the flu for the past three weeks. In case anyone was seeking a scalpel fix and hasn't yet read all of my archives, I've added a list of some of my favorite dusty old posts to the sidebar to keep you entertained while I replenish my creative juices and try to relight the fire in my belly.

Enjoy!

Why Texas Rocks

"As Barack Obama and Hillary Clinton race around Ohio and Texas for tomorrow's primaries, they are telling a tale of economic woe. Yet the real story isn't how similar the two states are economically but how different. Texas has been prospering while Ohio lags, and the reasons are instructive about what works and what doesn't in economic policy.

(....)

So tomorrow the eyes of America will be on these two states moving in different directions. Ohio has an economy burdened by high taxes and work rules that impose heavy costs on employers. Texas embraces free trade, keeps taxes low, doesn't impose unions on business and has tooled itself for 21st century global competition. Ohioans may not like to hear this, but for any company considering where to locate a new plant or move an existing one, the choice between Ohio and Texas isn't even a close call.

The challenge for our national economy in a world of competition is to become more like Texas and less like Ohio."

Oh, and there's this reason too.

UPDATE: And this, via AOS: Texas Rabbit of Death kicks Monty Python's ass.

Customer Service

Hello, hospital administrators! Do you really want your facility to provide outstanding customer service? Then do something about it.

No, not by cracking down on the overworked staff because they don't kiss patients' asses enthusiastically enough or because they aren't meeting your precious benchmarks.

How about properly staffing your facility instead of harassing the employees when your cost-saving efforts begin to undermine patient care?