EKG DU Jour #19: A Case of Obtundation

A 60 year-old man was found obtunded, unable to ambulate or communicate at home by a house cleaning service. He was brought to the emergency room and found to by hypotensive, bradycardic and was intubated emergently due to poor ventillatory effort. His initial potassium was found to be 7.6 meq/L and a slow junctional escape rhythm of 40 b/min. He was administered calcium, insulin and glucose, and the EKG, shown below, improved a bit.

Click image to enlarge

An astute observer glanced at the EKG and posed an important question to the ER staff.

What was the question?

-Wes

Addendum 18:45 CST - The EKG image was updated to permit better enlarged viewing.

Text Paging Health Information

I saw this in a recent nursing note:

Urine noted to be bloody without clots.
Text message sent to 2290 (trauma pager) about hematuria.
Patient denies any pain at this time.

No doubt patient identification or their room number, was sent to identify the patient (I'm not sure which). I suppose a record of the physician covering the trauma service that night is discoverable.

But I wonder, in the world of cyberspace with electronic communication carrying such an important role in health care delivery lately, is HIPAA really enforceable or will it just be used to extract huge fines from care providers now that the new HITECH policy expands HIPAA's reach.

Since text pages are neither encoded nor retained as an official audit trail of care delivered, it seems to me care providers are vulnerable, even when they are doing the right thing for the patient.

-Wes

Primary Care's Problem: Putting the Sexy Back

Hugh Laurie can't do it. (We need to cut back on over testing, doctor, and those pills!...)

Marcus Welby can't do it. (Who? You mean that OLD guy?)

8% pay raise through cost shifting can't do it. (And you want me to fill out how many forms?...)

Calling their clinic a "medical home" and flooding it with angry people who can't get an appointment won't do it.

So how do you do it?

How does one go about putting the "sexy" back in primary care?

This is one of health care reform's biggest problems and right now, just about every piece of legislation promised to further overwhelm primary care doctors with more hoop-jumping than ever before. From ICD-10 with it's 150,000 billing codes, to mandates to purchase expensive medical record systems that, so far, have proven their worth to administrative collection agents in their protected silos well before they have proven their worth to our nation's health. Or to pay for performance, a form of least-common-denominator medicine that forces compliance before enabling innovation in health care efficiency. Primary care is no longer sexy, it's becoming cookbook. So much so that nurse coordinators have become the new buzzword for primary care - not exactly a reason to enter four long years of medical school and three more years of residency training. Who wants to go to school of become a doctor only to find out that you're really going to school to become a nurse manager?

And then there's the academic mega-centers' disdain for private practice care. The not-so-subtle elitist attitude that private doctors in the community aren't nearly as good as the academic megacenters' specialist care, while they, themselves, have never set foot outside their pearly gates to work in the trenches lest their white coat become soiled.

Primary care is not about medical robots, waterfall lobbies, big screen TV's and marble floors. But those things are sexy. And we all know that Americans, like bugs, are drawn to bright and shiny objects. We love the whizbang, the big buildings, the nice decor. We scream for the latest and greatest hospital additions with computer technology and the latest robots, only to turn around the next day to scream about our hospital bills. God forbid we put two and two together.

Primary care doctors are up against all of this and the marketing efforts they employ. No wonder they cannot compete.

Putting the sexy back in primary care will involve anything but more bureaucracy and oversight. Congress does not get that these aren't sexy. To them, the tombs of legislation are what's sexy ("See all the work we did?")

But what's sexy to doctors is using independence and entrepreneurism in medicine for the patient's benefit. That's sexy.

And unless our legislators get that, primary care will go the way of the dinosaurs and the great paucity of care providers imposed by bureaucratic doctrine, will continue unabated.

-Wes

Addendum: Today we find that general surgeons are way ahead of primary care doctors in bringing sexy back to their profession.

It seems some are leaving the drab of emergency room call to fill SWAT teams in a "national movement" to embed medical professionals "so that help is at the ready should something go wrong."

Pitty the poor ER patient who finds the general surgeon is out on a drug bust.

US Health Care Reform Photoshop Contest on Its Final Stretch

Just a reminder: there's a little over 24 hours left to submit your entries to the US Health Care Reform Photoshop Contest where a single tastefully doctored photograph that summates your feelings about the health care reform efforts underway could win you an Apple iTouch. Entries are due by 11:59 PM CST and should be e-mailed to wes - at - medtees - dot - com. Full contest rules can be found here.

Good luck!

-Wes

When a Nurse Contracts Malaria

In 2008, Dawn Dubsky was a nurse at Children's Hospital in Chicago when she took a trip to Ghana, where she contracted malaria and all its complications. In a two part series, the Chicago Tribune chronicles her story. The results, in many ways, were profound:



-Wes

Putting the "Happy" in Thanksgiving

Who said hospitals can't have fun? Provident St. Vincent Medical Center, Oregon shows us how as they support breast cancer awareness:



Only one question: where were the adminstators?

Happy Thanksgiving!

-Wes

Some Thoughts for Thanksgiving

I thought I'd share this list that was published on this blog before:

I am thankful for the teenagers who are complaining about doing chores -- that means they are home and safe.

... for homework. It means we live in a country where education is valued and encouraged for all.

... for the taxes I pay; it means I have income.

... for the mess that I have to clean up after parties, because it means I am surrounded by friends.

... for the clothes that fit a little 'too snug' because it means I have enough to eat.

... for the lawn to mow, windows to wash and gutters to clean; it means I have a home.

... for the parking spot I found at the far end of the parking lot, because it means I am capable of walking and am blessed with transportation.

... for my huge heating bill, because it means I am warm.

... for the person behind me in church that sings off key, because it means I can hear.

... for the pile of laundry and ironing, because it means I have clothes to wear.

... for all the complaining I hear about the government; it means we have freedom of speech.

... for the alarm that goes off early in the morning because it means that I am alive!

Author unknown

And one other thought: be sure to visit Paul F. Levy's blog, Running a Hospital, to learn about the Engage With Grace program to how you can engage in a conversation with your loved ones about their (and your) end of life wishes.

Now, especially, is a good time to reflect on what we can do for others.

-Wes

When Insurers Dominate Market Share

Prices rise:

One factor that could be driving larger increases locally: Blue Cross & Blue Shield of Illinois, which historically has used its dominant 50%-plus marketshare to undercut competitors' prices, has been more aggressive with rates this enrollment season, brokers say.

"Blue Cross is the one company that is consistently coming in with higher renewal increases," says Rob Wilson, an insurance broker and president of Westmont-based Employco Group.

A Blue Cross spokeswoman declines to comment.

Funny that when hospital systems coalesce and raise prices to remain "competetive," the FTC cries foul, but when the insurance industry does the same thing, the FTC can't be bothered.

But then, the government knows what's best for patients, right?

-Wes

Code Blue, Then and Now

Then:

11:30 pm - Cackling though the overhead intercom system:
“Code Blue, Three East, Room 236”

A thunderous herd of medical students, residents, anesthesiologists, cardiologists, social workers, security personnel descend on the scene. Arriving, the chief resident is in charge at the foot of the bed. IV’s have been started, some young well-muscled individual is bobbing up and down on the unseen’s chest, brow glistening with sweat, but focused. An anesthesiologist, noting the agonal rhythm, works to secure the airway, then a central line. Nurses administer drugs, bring line kits. Airway secured. “EKG? Where’s the EKG?” Electrode replaced. “Story? Who’s got the story?” Ten. Twenty. Thirty. The minutes pass. Finally, silence, as the monitors removed and the group departs. Like sound and fury, signifying nothing.

Now:

11:30 pm – The pager sounds:
* bleep bleep bleep *
A digital image appears on the screen: CODE BLUE, Room 2001

I was not on call, but I wondered, “Was this a patient of mine?” “Did I forget someone?” I raised my head from the pillow and strolled in to the accompanying room where my outdated computer sat and waited while it booted. “What might have happened?” “Is it someone old or young?” Thoughts spun just as the disk drive. Waiting. I typed by keyfob’s codes, I entered by password twice, I waited some more then the electronic medical record appeared and I checked the name next to the room number. For the first time, the number meant something: a person, 88 yrs old, yet someone I did not know. The scene appeared from miles away.

I sat back and perused the chart. Heart attack, conservative management, hypotension, fluid bolus given, then nothing more.

A few more keystrokes and the computer went black.

Then sleep came poorly once again.

-Wes

Want To Opt Out of Medicare?

Here's how, courtesy of Mayo Clinic Family Medicine - Arrowhead (Arizona):

The discrepancy between what Medicare pays and our cost of providing care acutely impacts the sustainability of our primary care practice. Medicare reimbursements do not cover our actual costs of providing care, and therefore we have recently had to make some difficult decisions that will impact the Arrowhead Family Medicine practice. Effective January 1, 2010, the physicians at Mayo Clinic Family Medicine - Arrowhead will opt out of participating in Medicare, meaning that Medicare will no longer reimburse for the services they provide....

With the $500 billion dollars of cuts to Medicare spending in the new health care bills proposed, will we see more of this in more affluent areas?

-Wes

Early Health Care Reform Photoshop Entries Are Up

Early US Health Care Reform Photoshop Contest entries are available to view here. (I did the one at left - sorry, it's ineligible). There's still plenty of time to submit your entry. Entries will be still be accepted until 30 Nov 2009 at 23:59 pm CST!

-Wes

As Hospitals Gain Cardiologist Employees, Private Cardiologists Are Shunned

An interesting story has developed in Missouri where a private group of cardiologists was asked to no longer see their patients at the local hospital. It seems the hospital hired it's own group of cardiologist-employees. Things grew so contentious according to the video accompanying the report, when the cardiologists asked for an OR lite, they were told to use a flashlight (the hospital disputes the claim).

As the cardiologist shift to adjust for the economic realities that confront them, they have much more to lose from their patient relationships as its the patients that are inevitably affected the most when these shifts occur.

-Wes

Sebelius: Talking the Talk or Walking the Walk?

Here's a bit of the transcript from Kathleen Sebelius, Department of Health and Human Services Secretary, speaking to the Wall Street Journal's CEO Council (approximately 2 min, 45 sec into video) about saving health care costs:

... There are lots of features of the House Bill and that are already in the Senate bill that change that (the way doctors are paid). We are beginning to move away, particularly in Medicare, from traditional fee-for-service pay that I would suggest not only causes redundancy but doesn’t encourage innovative, high quality, low cost practices to moving toward a system that exists in pockets, exists in Mayos, Geisinger, (Inter-)Mountain Health Care. We know what it looks like. It isn’t how medicine is practiced it isn’t the the hospitals and providers are paid, so "bundled payments," "medical care homes," "accountable care organizations" – all buzzwords for really providing financial incentives and eventually financial penalties for appropriate medical protocols and appropriate outcomes - stopping the system now where one out of every five who’s released from the hospital is back in 30 days having never seen a health care provider, reducing or eliminating hospital-based infections, which are now one of the top 10 leading causes of death in America. We know exactly the system that can be done to stop it. It doesn’t take any capital investment It doesn’t require any new technology.”

I wonder what she means by "... eventually financial penalties for appropriate medical protocols and appropriate outcomes?"

Why penalize people for adhering to appropriate medical protocols? Or maybe she just needs some sleep...

And then there's this quick fact check:

Septicemia: #10 in 2006 (1.3% of deaths) CDC list for death in America and was #11 in 2004 (1.4%) but is substantially better than rates in 1997 (2.4% of deaths).

(Just keeping it real.)

-Wes

Medical Bloggers' Grand Rounds Is Up

... this week over at Colorado Health Insurance Insider.

-Wes

Compensating Doctors for After-Hours Call Coverage

Should there be a premium added to physician compensation for on-call coverage after hours, or are Medicare rates enough?

This appears to be the central question between two competing hospitals in Longview, Texas where a $300,000 stipend was paid to a cardiology group by one hospital and not the other for cardiology on-call coverage.

Guess which one the doctors are promoting now?

Banos said the Diagnostic Clinic cardiologists recently approached Good Shepherd "demanding hundreds of thousands of dollars in compensation from Good Shepherd for providing call coverage to the patients of Good Shepherd."

"This is in addition to whatever money they are able to bill and collect from patients and their insurance companies for the services they actually provide when they are called in to perform a procedure," Banos said in his e-mail to Good Shepherd employees.

Banos said he believes the demands for compensation were "veiled threats to move their elective procedures to Longview Regional if we did not pay." He added Good Shepherd's stand is that meeting the compensation demands would "not be fair to the many other physicians on our medical staff who selflessly and without any expectation of pay [from the hospital] provide call coverage to our patients each day as part of their commitment to the community."

"We cannot meet the needs of our community and pay doctors for doing something that they are already obligated to do as a part of their community obligation" Banos said.

Banos said he believes Longview Regional agreed to pay the cardiologists more than $300,000 a year for on-call coverage.

"We do not believe that it was by chance that it was only after this agreement was reached that these physicians touted Regional's 'commitment to quality care' and announced their 'choice' of Longview Regional for their patients." Banos said. "We knew that taking a stand could result in these physicians moving their elective cases to Longview Regional, and it did."

Before condoning the cardiology groups' actions strictly on the basis of greed, we should note that there is a precedent for higher pay for employees working after hours in industry. Hospitals, too, have resorted to paying "nocturnists" (night-shift hospitalists) higher salaries than their daytime hospitalist counterparts as they struggle to find staff willing to work the night shift managing inpatients. These salaries are not covered strictly by funds received from the paltry Evaluation and Management payments paid by Medicare, rather, they are subsidized by the hospital system.

Threatened with unprecedented pay cuts from Medicare, look for this trend to continue as doctors use their only remaining asset, patient referral clout, to negotiate their compensation going forward.

-Wes

How Not to Consent a Patient for Angioplasty

Yikes!

"Honey, all you need to worry about is if I am going to listen to opera or Steely Dan during the procedure."

-Wes

P.S. I told you "Honey" was bad.

US Health Care Reform Photoshop Entries

Last updated 24 NOV 2009 @ 06:00 AM.

Early entries for the US Health Care Reform Photoshop Contest are shown below in the order they were received. Remember, the deadline for entries is 11:59 CST 30 Nov 2009. This post will be updated from time to time as new entries arrive.

(Editor's note: We're putting the entries up as they're sent. Remember, you'll ultimately be the judge.)

1) "Health Care Cat" (in the spirit of LOLCats):



2) "Gonnorrhea for Rationed Health Care"



3) "Healthcare Budget":



4) "Taking Care of the Healthcare Pest":

US Health Care Reform Photoshop Contest

In the spirit of the upcoming holiday season and to make sure something on health care reform gets done before the end of the year, Dr. Wes and his wife, Diane, would like to propose the first (and perhaps only) US Healthcare Reform Photoshop Contest.

Bring us your snark, your wit, your creativity about the health care reform efforts encapsulated in a single photograph. Photographs in support or against the current efforts will be equally considered, and you, dear internet devotees, will be the final judge. The winner receives an iPod Touch.


Rules: No more than one photo entry per household, please. Create a single photo using Photoshop or other equivalent photo-editing software that encapsulates the essence of health care reform as you see it. Photographs must be G, PG, or PG-13 rated and family-friendly (R or X-rated photographs will be enjoyed, but not eligible or posted). An example image we created is shown above. Please do NOT use copyrighted photos.

E-mail your entries to me at wes - at - medtees dot com (please keep file sizes under 100K) with your name, address and e-mail contact information and I'll post the vetted entries on a webpage on this blog in the order they are received. If the response is overwhelming, we reserve the right to limiting the images posted to our discretion.

Depending on the number of entries, our highly distinguished referees (my wife and I) will choose the five or six photographs that will serve as the finalists by no later than 11:59 PM on 30 November 2009. On 2 December 2009 or so, the chosen finalists will be displayed and the polls will open for you to choose the winner. The photograph with the most votes tallied will receive an 8Meg iPod Touch. Voting on the finalists will close 11 Dec 2009 at 11:59 PM. This way, we hope there's plenty of time for our prize to reach the winner before the holidays and final health care reform vote. In the unusual event there is a tied vote, we will chose the winner between the two favorites.

So get going, be creative and most of all, have fun!

Happy holidays!

- Wes and Diane

P.S.: Please spread the word!

FTC Disclaimer: No advertising sponsors are supporting this contest.

Addendum:

If you'd like to help promote this contest on your blog by placing this tacky button on your sidebar, just copy the HTML in the textbox below and add it to the your blog's sidebar code:

<a href="http://drwes.blogspot.com/2009/11/us-health-care-reform-photoshop-contest.html"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 120px; height: 120px;" src="http://www.medtees.com/blog/HC_Contest.jpg" border="0" alt="Health Care Reform Photoshop Contest Rules" /></a>

The entries so far can be viewed here.

Problems With Low-Energy External Defibrillators?

Seems the FDA wants to know more:

FDA is investigating energy levels in (automatic) external biphasic defibrillators (AEDs) with shocks ≤ 200 J. FDA has received reports of 14 events since 2006 in which a 200 J biphasic defibrillator was ineffective in providing defibrillation/cardioversion therapy to a patient, whereas a subsequent shock from a different 360 J biphasic defibrillator resulted in immediate defibrillation/cardioversion. The majority of events occurred during attempts at cardioversion of atrial fibrillation, but there was at least one instance with defibrillation of a ventricular arrhythmia as well. FDA is seeking additional information in order to interpret the significance of these events, and to determine whether FDA activities are advised.

I haven't seen this, but others may have, so let 'em know.

-Wes

Waiting, and Hoping, For a Heart

A patient, recently listed for cardiac transplantation, tells his story about being rejected, then accepted, to the cardiac transplantation list:

Next week, I'll check into Mayo, one of the world's premier hospitals, to undergo additional treatment in preparation for receiving a new heart. Since my brain tumor turned out to be benign and my prostate cancer has responded to treatment, doctors there said those issues no longer should disqualify me as a candidate for a heart transplant.

Now that I'm on the list, I am on an around-the-clock standby alert. I have to be ready to be on the operating table within four hours once a compatible heart becomes available. The fact that Chicago is 331 miles from Mayo, in Rochester, Minn., complicates things since I don't have my own charter jet. But the Mayo Med Air charter service could assist me if a commercial flight can't get me there quickly enough.

The challenge now is the wait. The heart I need will become available only when the donor is declared brain-dead and his heart can be taken from him and implanted in me within four hours. I am told the fact my blood type is B positive increases the chances of me getting a transplant quicker, though there are other patients ahead of me.

I had wanted it all to happen at the University of Chicago Medical Center, where world-renowned Dr. Valluvan Jeevanandam, who performed a triple-bypass on me in 2001, has done more than 1,000 transplants. But that hospital takes a more conservative approach to the fact my prostate cancer still is in remission. They wouldn't put me on the transplant list until I had been using an implanted heart pump ''for several years.''

Fortunately, the Mayo Clinic and Northwestern Memorial Hospital feel I have progressed enough in my recovery from the slow-growing prostate cancer to be eligible for a heart now.

With the competetion for patients underway as the large health care system land-grab extends across state lines and overseas (See here and here), have the selection criteria for transplant patients remained a form of rationing or really become a form of marketing?

I wonder.

-Wes