R- Rated quote of the week

August 31st, 2006

I actually had 4 days off this week, so I have been using power tools instead of treating those who were drunk while using power tools. However, the Mecca work is never done; I also spent a little of my free time responding to a patient complaint about one of my residents, who of course has moved away and left me to soothe the feelings.
Last years chief resident was a self proclaimed “half black, half white trash” dynamo that was one of the best residents to ever come through the program. She was bright, thorough and efficient but when it came to sensitive areas of patient counseling she was a real ball buster. As attendings, we just kind of stood back and watched… like viewing a plane crash, except in this analogy the pilot had full control. I mean what were we going to say to her? She had pulled herself up by her bootstraps to go from a trailer park to medical school and if anyone EVER had the right to tell public housing folk “the way it is” then it was her. I suppose if anyone outside myself knew how pathetic people could be it was her; it was kind of our bond, how hard we both had to work to get here, so I don’t mind handling this one complaint… not much anyway.
It was sometime near the end of her residency, a shift in Peds and our complaint comes from the mother of a 15 year old. The “child” had presented with “mouth pain” and upon examining the patient my resident found a freshly placed tongue ring.

Res- to the mother, ” uh, hmm do you know what’s in your daughter’s mouth?”

Mom- “an infection?”

Res- “yes, an infected tongue ring.”

Mom- “yeah it’s only been in a few days… I told her to gargle with salt water but she won’t.”

Res- to patient “having you been using that thing?”

Patient- nods no… looking at the floor.

Mom- “using that thing?”

Res- “yes, you know USING IT… you are suppose to wait a couple weeks.”

Mom- “you mean eating with it in?”

Res- “uh, no.” to patient, “why don’t you explain that to your mom and I’ll go get you started on some antibiotics”

The resident then comes out of the patients room, leaving the door open, and exclaims to me, “I swear, if you spent good money on a tongue ring for your teeny-bopper you should at least get a free T-shirt that says, ‘MY DAUGHTER SUCKS C**K!’ “… after which no small amount of laughter erupted. This was followed in turn by an angry outburst, of which I cannot recall the specifics, and the patient-mother fellatio team storming out of the Pediatric ER.
So now, I am answering the complaint… by letter. NO WAY could I keep a straight face on the phone.


Ewww Candy!

August 27th, 2006

(one of the offending pills… yep, looks like a sweet tart)

We have had many serious pediatric poison ingestions here at the Mecca; diabetic pills, grandma’s heart medicine, anti-psychotics, lye, paint solvents, baby oil… nasty players in the world of child killing toxins. Most end up being fairly benign and many of these were accidental and would’ve have been difficult to prevent; how many parents know that a few swigs of baby oil could put their child in the ICU for a month? (come to think of it, we used to keep ours on the corner of the bathtub).

 Some poisonings , however, occur out of absolute carelessness. The one that stands out in my distant memory is the 4 year old that I had in the Peds ICU for over a month after he drank a mouthful of paint thinner that had been storedin a plastic Hardee’s cup (cap and straw included) under the kitchen sink. Petroleum based products, especially aromatic ones like lacquer thinner, work thier way into the victims bronchial tree and keep the alveoli in our lungs from working properly. Such an ingestion causes the child to look fine for about an hour and then spiral down to being unconscious in minutes… there is little in the ER that makes me more nervous.

No one is invincible from child poisoning. In fact, another ingestion that I will never forget happened when I worked in a hospital pharmacy in college. We had these large jars with narrow necks filled with colorful, out of date pills as decorations. The jars had no caps and we just filled them as we went, also they were so heavy we sat them on the floor next to ourdesks. One day a pharmacist brought his toddler into visit… ewww Candy!

Our recent pediatric overdose went like this:

Mom: “I think my child swallowed a bunch of sedatives.”

Trenchy: “I see… what happened?”

Mom: “I walked into the kitchen and saw him with these in his mouth.”(shows me the partially chewed pills that look like Sweet Tarts.)

Trenchy: “what are they and how many did you have?”

Mom: “I don’t know, some sort of sedative a friend gave me… I never counted them, they were in a zip lock bag.”

Trenchy: I could make out the lettering on the pills and knew I could likely figure out which drug it was… ”could the child have gotten other pills?”

Mom: “NO! absolutely not.”

Trenchy: “how can you be so sure? We REALLY need to know… are there any other drugs in the house? even tylenol.”

Mom: “yes we have some non-prescription drugs but nothing else.”

Trenchy: “so not even tylenol was kept with these?”

Mom: “no, those were kept in a kitchen cabinet where we keep the candy… he also ate a bunch of the candy.”


What do you say?

August 23rd, 2006

We recieve trauma victims from all over the state and, in particular, we see quite a lot from I-95 in the corridor between Dillon and Colleton counties. Over the years I have witnessed the aftermath of an untolled number of tragedies from that stretch of highway. So many in fact that only a few actually still come to mind… the German family on vacation, the pregnant lady and her kids driving to see the father as came home from Iraq, the Duke freshman heading home for Christmas.
A few months ago I met another family that I shall never forget. A fairly large, tight-knit family from Florida was headed to the Northeast to visit relatives over the holiday. It included a mother and her 5 children as well as the children’s grandparents who owned a van large enough to hold the entire crew. The Grandfather, of course, was driving. The children’s mother took some time to take a nap in the back of the van and at some point the 3 year old began crying. To soothe the child the grandmother let the 3 year old out of her carseat and held her in her lap, just for a while so the mother could sleep. Minutes later several cars, the van among them, collided in the rain. Loosing control, the grandfather managed as best he could but ran off the interstate and down a steep revine. The van rolled over.
The helicopter brought the grandmother to us with this report; “Motor Vehicle Crash I-95, Rollover, 63 year old female with open lower extremity fracture. 1 dead from the vehicle at the scene, 6 others with minor injuries traveling by ground ambulance.”
Our patient was very stoic given her injuries. She never complained and honestly I’m not sure she spoke at all except to answer our routinely annoying questions. It wasn’t until after we were finished with all the Cat Scans that I learned from the highway patrolman exactly what had occurred. “Looks like the 3 year old was ejected and the van rolled over her… it really wasn’t that bad of a wreck.”
It’s not an unusual story for us. 7 belted patients alive, 1 unbelted patient dead… we’re usually fairly numb to it. We can’t turn back time and we sure as hell don’t qualify as judges of others.

So prior to my patient going to surgery for her ankle, I went in the room and asked her would she like to see her grandchildren. She had visited with her husband and daughter (who were fine) and the kids had all been treated and released from pediatrics. She said “ok”, but then called me closer… (thinking back on it I had been fairly emotionally distant to her, I could only imagine what she was feeling)… and she asked me, “am I the reason my grandbaby died?”

My fake answer, at the time, seemed to be convincing, “no mam, you can’t think like that” ,as I grabbed her arm (for some reason her arm not her hand), “none of us ever know why.”

I have since thought about that a thousand times. I don’t think that I was very convincing at all.


Culture Clash

August 21st, 2006

Outsourcing is not just for business anymore. The practice of Medicine in this country has decades of experience in utilizing non-American physicians. We refer to them as Foreign Medical Graduates or FMG’s (despite a recent trend for them to get rather upset at the mentioning of those three letters.) It’s not a bad deal, really. Our nation gets an intelligent, diverse, hard working group of physicians involved in the healthcare system and they enjoy a typically free education in their homeland and then the fruits of a market economy. (pretty sweet considering we natives average $150k in loans)

Sometimes, however, the differences in cultures between the FMG’s and the locals can cause not only interpersonal conflicts but diagnostic and therapeutic pitfalls as well. A few FMG’s just never really get a good grasp of our culture and it is quite clear to me that it is to the detriment of patient care. OK, let’s be frank, some of them are just down right dangerous… but as always I try to find the humor.

Case in point was our new rotating resident (not in our residency of course) from China discussing a patient’s case with a patient’s wife. It was clear to us that the entire family was grossly intoxicated and that the patient was quite a terminal alcoholic. My Chinese resident, God Bless her, well… she was oblivious.

Lady- “how’s my baby, is he gonna go home.”

Res- “oh, um I am a sorry… baby?”

Lady- “my husbandt, yall done finish wit him?”

Res- “oh, ah yes a mam, he is gettern some fluid and we watch him a while.”

Lady- “uh huh. well he’s a wantin to go and we waitin on my cousin to ride us back to Winnsburra.”

Res- ” uh huh, I see, but she needs some fluid in IV because she not drinking enough.”

Lady- ” she? she who?”

Res- ” oh, hahaha, I mean a HE… he not drinking enough.”

Lady- “shoot, he dranks all the time, dats what his prollem is… he drank 3 fawty’s dis mornin.” (holds hands to show a 40 height.)

Res- “Oh no no no… he not a drink enough is his prolblem. His blood shows he is a dehyrdrated… he must a drink much more.”

Lady- “Lawd a mercy… I aint ever heard no docta say dat befow.”


Funny of The Day

August 20th, 2006

 

An extremely busy day at the Mecca today; there are no hospital beds so anyone who needs admission to the hospital sits in the ER. Of the 23 beds that we use to see seriously ill adults, 19 are filled with patients who have no place to go. That leaves us with 5-6 beds including a few hallways stretchers to treat those that are seriously ill. Presently about 30 patients are waiting in triage to be seen***…. you get the idea.

However, there is still humor to be found. Our patient in the eye room is a prisoner from SCDC with a vitreous hemorrage; he seems like a really nice fella to be a prisoner and he must be fairly trustworthy. He came up to the front desk and asked, “have yall seen my guards?”

They apparently left to get “a quick snack.”

***- of note, many of those patients will wait 10-12 hours to be seen by a physician. EMTALA prohibits the staff from notifying patients of the long wait. The Feds believe that once notified of the long wait patients will leave the hospital and that would be a “barrier to care.”


Just So You Know…

August 16th, 2006

 

Preface- OK, so I took a break after the weekend of death. I went down to the Swamp and got on the tractor; did a little bush-hogging, planted a some grain and climbed a few trees. Screw Prozac, I have a 1948 Ford 8-N tractor with associated implements of destruction… I don’t need any of those “brain chemicals”. In fact it got me to thinking, perhaps we need fewer drug addiction “clinics” and more drug addiction “farms”.

Today’s Post- It occurred to me this morning that few people outside medicine realize how hospital “on-call” systems work and in fact how the on-call system is proving to be the proverbial canary in our Health System coal mine… wait a second I don’t hear any chirping.

The Emergency Medical Treatment and Labor Act (EMTALA) was passed in 1986 to ensure that everyone in the Nation has access to emergency care. EMTALA was the Federal response to hospitals that refused unfunded patients and, in part, insists that everyone who presents to a hospital for care receive a Medical Screening Exam (MSE) and any care needed to stabilize their illness until it is amenable to outpatient care with no regard to the person’s ability or willingness to pay (including, for example, coronary bypass). EMTALA rules are enforced by the Center for Medicare/ Medicaid Services (CMS) and nearly every non-federal hospital in the country falls under it’s jurisdiction. Penalties for breaking even one EMTALA rule are cost prohibitive enough to bankrupt most physicians and hospitals.

Part of EMTALA instructs hospitals to keep on-call lists of physicians in all specialties provided by that facility so that patients can have access to those specialties at all times. For example, if a patient shows up in the ER with chest pain and is diagnosed with a heart attack then a cardiologist who is designated on-call to see “unassigned” (patients without a cardiologist OR WHO DO NOT MENTION A PREFERENCE) patients that day would be consulted to further care for the patient. Should bypass surgery then become needed a cardiothoracic surgeon on-call would be consulted. There is no option for the emergency physician to choose another specialist who is not on-call for the patient; the call list must be followed. I shudder to think about the unsavory physicans who have been thrust upon unwitting patients in such a manner… and, of course, vice versa.

Sound alot like a National Healthcare Service? Well it is, an unfunded one… unless you consider cost-shifting (eg- a $23.19 aspirin) to insured patients a funding plan.

So what kind of problems does EMTALA add to the already overburdened system?

-Hospitals have moved to provide services with only the choicest reimbursement profiles to make up for losses from EMTALA. This is not difficult to see even in the Midlands. You can’t swing a dead cat without hitting a Heart or Obstetric Center but if you are in a major car crash or have an ill child then 4 of the 5 hospitals in Columbia would much prefer to look the other way. (by the way if you have a cat near death, vets don’t give a rat’s ass about EMTALA)

-Many specialists have moved to privately funded outpatient clinics to avoid having hospital privileges and thus the requirement to be on-call for the hospital. Fewer specialists means more hospitals lack basic care providers like orthopaedists, dentists, plastic surgeons and ophthalmologists.

-Fewer specialists means much longer ER and hospitals stays and higher costs. Longer waits add to malpractice problems further accelerating the spiraling loss of specialists.

-Patients with borderline income utilize ER’s for care instead of less costly urgent care’s or family doctors that may demand immediate payment. This propagates the problem of hospital overcrowding.

-Patient choice is a non-entity. Unassigned patients have little to no say in which specialist will care for them. Informed patients can wisely ask for a specific physician but there is no guarantee since many specialists will simply not take unassigned patients if it is not required of them. The combination of lack of funding and (at least a perceived) increase in malpractice risks lead most physicians to avoid caring for an unassigned patients at all costs.— A good example was last week. A middle aged lady was stuck in the jaw at a bar causing a fracture. She was referred to the facial trauma specialist for care. The surgeon saw her in the office promptly but he proceeded to be very insulting (not a surprise to us) to her. She left his office and return to the ER for another consult but we could not find another specialist to see her.

-Private clinics and Military hospitals continue to shunt patients to public hospitals adding to overcrowding.

The bottom line is that the health care system in the country is at it’s breaking point. The problems are monumental and can not even begin to be addressed until we decide that the system can not be everything to everyone and if EMTALA is any indication, our present leadership has no capacity for productive change.


8-13-06, A Two Wheeled Bloodbath

August 13th, 2006

Several cardiac arrests today. One person’s only family member was an 11 year old girl. I simply could not tell that little girl her Daddy had died when she had no family to be with her. Her aunt showed up later and I am so very glad I waited.

 3 motorcycle crashes today. One in intensive care with severe head injuries. One in the ICU with a smashed liver. One in jail for felony DUI… and the youngest… the one with the helmet… the female… the one passenger…the single mother with a two year old, dead.

I don’t know how to explain it, perhaps it burns up my adrenaline reserve but such tradgedy makes me unbelievable tired. Exhausted.


OK, so only 30 Million

August 12th, 2006

For Sale: 2001 Scout Boats 201 Dorado (Anniversary Edition). 2001 150HP Yamaha Salt Water Motor with SS prop. New custom installed (by me) CD player with speakers and Garmin GPS, Fishfinder and surface temp. Oval shaped live well. Bimini top. Stainless steel tow bar. Includes stainless steel rodholders and complete Striper fishing set up with 6 rod/reel combos as well as 4 adult, 4 kids lifejackets, a wakeboard and two innertubes with rope. Also great for Bay fishing. Only stuck in the flats during low tide once. Low hours.

Make an offer, but I need around $8K to cover malpractice premium adjustment.


Who Pays?

August 9th, 2006

(attorney Geoffrey Fieger and pal) 

Where does the money come from in multimillion dollar verdicts? Often times it is consumers or John Q. Taxpayer. However, in the case of malpractice in the State of South Carolina look no further than old Trenchy. You see, hospitals have a limited liability (way less than a million), so if a 55 million dollar verdict is handed down in this case in Lexington then the physicians in this state who participate in the Patient’s Compensation Fund (PCF, that’s nearly all of us) get to split it up.

“But Trenchy, that doesn’t seem like alot of money to me.”

OK, well (par example’) a few years back, a 17 million dollar award was given to a patient who had a bad surgical outcome. The surgeon in the case was hired by the hospital despite very shaky credentials but in testimony the hospital said it had no other surgeons willing to come to the area. Obviously, no physician in the state had any say in hiring him but “to punish the hospital and the surgeon” the award in that amount was given. At the time of the award said sawbone was malpracticing in another state and the hospital paid $500,000.00, an amount that is capped by law. The PCF crew picked up the rest of the tab. My malpractice premiums went up 1000%.

So I sold the lake house and bought a place nearby; who needs those damn geese anyway. Perhaps this time I will wise up and look around Charlotte or maybe Atlanta… or maybe I should join my buds out in Colorado Springs. Hmmm, at least I could get away from the Star Jones wannabe’s.


Top 11 List, Part Duh

August 9th, 2006

 

 We really noticed a reduction in the number of EMS visits tonight at the Mecca and while scrolling through The State Newspaper Website (why would one EVER pay for it?) I noticed a blurb about 911 service being down in Richland County throughout the evening.

Well, that pretty much explains it… but I wonder, what must have gone through the minds of the locals when there was no answer to their 911 Emergency. (hopefully we don’t find out later that someone died.)

So I bring to you, from the author of Camouflaged Vehicles: Dangerous at Any Speed,

The Top 11 Things Said When No One Answered 911 calls in Richland County:

1. “Well the baby still has a fever… I guess we’ll call The Poison Center, where’s that Mr. Yuck sticker?.”

2. “We will just have to wait it out… what channel is Jerry Springer on?.”

3. “Just hold pressure on it, that’s all they do every-time you get shot anyway.”

4. “Let’s try having sex again, maybe this time it will make your belly pain better.”

5. “Holy Crap 911 is down… turn off the Dr.’s Care sign… TURN OFF THE DR.’S CARE SIGN!!!!”

6. “Hot Damn, grab your mask… 911 don’t work.”

7. “call 411, tell ‘em 911 ain’t workin.”

8. “C’mon we’ll just walk across the street to Providence… the nuns ain’t there to check your wallet at night.”

9. “Ray Ray, walk down to the Hot Spot and fetch Granny an ambulance.”

10. “Hell no we ain’t drivin, gas is 3 dollars a gallon and Medicaid don’t cover that… yet.”

11. “Ah hell boys, pop me another top… looks like I’ll won’t be rehabbing till tomorrow.”