EMTALA-rama

Let's imagine that, hypothetically, you were an individual of Hispanic descent who spoke not a word of English, and you suffered a horrible injury in Mexico which led to a stay of several weeks in a Mexican hospital. You would never walk nor recover the ability to care for yourself ever again. You would need to be fed, suctioned, and turned in your bed every 2 hours for the rest of your life. You would probably need several more expensive procedures over the next few weeks, but your current condition had been fairly well stabilized.

Fortunately for you, your family was able to scrape up the money for an aeromedical flight to the US, and somehow they were able to produce some sort of proof of citizenship that enabled your entry into this country. So they checked you out of the Mexican hospital and brought you to the airport, where your journey to the US and our bountiful (and free!) healthcare system could proceed.

Of course in our hypothetical scenario you are uninsured, and your local family spent all of their money on your treatment in Mexico, maybe a few bribes, and your medical flight here. But those are only minor inconveniences, really, thanks to EMTALA. You don't need no stinking MOT (transfer approval), you don't need to have an accepting physician, you don't even need to bring any paperwork or X-rays from the other hospital. And you certainly don't need insurance coverage. No copay? No problemo.

All you need to do is show up. Any ER will do, and we're open 24 hours a day even on weekends. Just pick the nicest hospital you know of that is most convenient for you. Don't bother going to those busy, dirty, impersonal county facilities. You deserve the best! It's your right.

You might get (relatively) lucky and happen to have an incidental emergency medical condition that requires hospital admission in order to stabilize you. Honestly, that would make both of us lucky, because it would be pretty hard for someone like me to discharge someone like you who can't care for yourself and whose family has made no other arrangements for your care. But it's also pretty hard to admit someone like you solely to arrange long-term nursing home care and rehabilitation, even if you might need more procedures in the upcoming weeks. No matter how sad and unfortunate your situation may be, "social" admits to the "no-doc" admitting staff are usually about as welcome as a fart in an elevator. Particularly when they are unfunded midnight weekend language-barrier system-abusing complicated social admits of questionable medical necessity.

When patients like you get admitted, you tend to be challenging for the hospitalists to discharge too, so you end up receiving much more medical care than the emergency stabilization which is mandated by EMTALA. And that is both the beauty and the curse of that legislation.

A Massive Workload

One of the most amazing physicians I've ever known told me that he is currently managing an inpatient service of 60 patients, including several ICU patients. He has a cadre of well-trained aggressive medical students to help him, but no residents. He is the attending of record for each of these patients, not a consultant.

I've never heard of such a caseload, and I can't imagine trying to keep up with all of those patients. I gave him three more admissions today, unfortunately.

The 30 Minute Guarantee

I think it's a dumb idea. The Unlikely Heroine wants to know what you think about it.

Suburban Emergency

Here's a wonderful new blog by a suburban ER doc.

This post is a great example of some of the trench battles we deal with. Sometimes the patient care isn't the most difficult part.

h/t The Physician Executive

The Refuser

An older gentleman presented with vague complaints of not feeling well, just getting over "the flu," maybe a little dizzy, etc. He really didn't want to be there, and he definitely wouldn't have come if his family hadn't insisted. He minimized his complaints and wouldn't elaborate on any of them. He was alert and looked fit for his age, as one might expect of a man who did 100 pushups every day. Of course his troponin was elevated.

"Sir, I know you didn't really want to come in to see us, but I think you'd better let us put you in the hospital for a couple of days."

"Well, I can tell you right now son, that ain't gonna happen."

I didn't think so. After I explained the risks of going home and the need for further testing, and he explained his philosophies about God, death, and doctors, I only had one last suggestion for him.

"If you don't take any other piece of advice I have to offer, I wish you would do just one thing for me. Take this aspirin now, and take one every day."

He wouldn't even do that. And he wouldn't sign the AMA form either. He might as well have stayed home, really.

Economic Stimulus Package

What a fancy name that is. Too many syllables though.

"Tax Relief?"

That's a noble concept. We all want tax relief, right? But since those who pay three-fourths of the income tax in this country won't be getting any relief from this package, perhaps that isn't the right term to use.

"Tax Rebate?"

Yes! Give the taxpayers some of their hard-earned money back. That ought to be good for a few votes. Of course somewhere between 30 and 50 million people who pay zero taxes will be getting a government check, so maybe rebate isn't the right word after all.

No, let's just call it welfare and move along. Karl Marx would be proud. This redistribution of wealth is just a disguised way to widen the already perverted progressive taxation scheme.

I guess reducing the federal deficit isn't that important after all.

Don't take my word for it. Here's a roundup of some actual economists' views.

Who would have guessed President Bush would turn into Jimmy Carter?

The Veterinarian

"My cat has bumps on it."

It took me a few seconds to understand what she meant.
Did she say "calf?" Maybe she had some ant bites or something.
Nope, it was her cat. And it was foaming at the mouth too.

Time to put it down. That's a sick cat.
(language warning)

Anonymous Career Counselors

Of all the angry anonymous comments I read, my favorites have to be the ones that suggest that I find another line of work. These individuals simply cannot believe that someone who writes the things that I do could possibly be a caring, compassionate, competent physician. They view me as the symbol of every ER doc who has ever denied them their narcotic of choice, questioned their honesty, neglected their concerns, made them wait too long, rushed them through a visit, or spoke to them in a less than satisfactorily ass-kissing manner.

And because they are experienced ER patients, they think they know what qualities emergency physicians should possess. Apparently the willingness to dispense Dilaudid on demand is high on their list, but they also expect the complete absence of cynicism even when we are off the clock. They don't want a doctor...they want Jesus with a syringe.

I enjoy these sorts of comments not only because I'm an enthusiastic shit-disturber, but because I also believe that I am providing a sort of therapeutic service, free of charge. I'm charitable like that. When these folks' unrealistic expectations are unmet, their angry complaints to the hospital administrator are fruitless, and their carefully-typed rants to the patient relations department are answered with a generic form letter, they need somewhere else to vent their frustration. Disgruntled patients, I'm your huckleberry.

Incidentally, my real-life patient complaint file has exactly one letter in it over the past year which isn't even a complaint at all; it's a thank-you letter which praises my bedside manner. So vent away, suffering idealists of the world. I'm here for you. You can thank me when you see me.

The Long and Winding Road

Sometimes a difficult diagnosis is made by skill, and other times by happenstance. This case required a bit of both.

A four year old boy complained of fever, headache, and neck pain for 1-2 days. His pediatrician had evaluated him that morning, found no evidence of bacterial infection and recommended supportive care. When the headache worsened and the patient could not move his neck without screaming, the family sought medical attention later that evening. He denied any sore throat, earache, or pain with swallowing. There was no cough, vomiting, or diarrhea, but the family admitted to decreased oral intake that day. The worst pain was apparently in the left parietal area, and was only partially relieved by Tylenol at home. His parents were very concerned about the possibility of meningitis.

He had a temperature of 103 orally, a heart rate of 150, and he was alert but moderately lethargic. His respiratory rate was slightly increased but not labored. Although his tonsils were symmetrically enlarged, they were otherwise normal without erythema or exudates. His tympanic membranes were normal. His neck was supple with no meningeal signs, but revealed multiple small anterior cervical and submandibular lymph nodes bilaterally which were mildly tender to palpation. He complained of neck pain when he rotated his head, but not with flexion. The rest of his exam was unremarkable.

His rapid strep and rapid influenza tests were both negative. His WBC was 22,000 with neutrophilic predominance. A lumbar puncture was performed which revealed an opening pressure of 27cm (normal is 5-15cm), but the spinal fluid was clear with essentially normal laboratory studies. The patient received IV Rocephin pending the CSF results. Because of the elevated opening pressure in the setting of normal CSF studies, I ordered a CT scan of the brain which was initially reported as entirely normal by the Radiologist.

By this time, the patient's headache and fever were only distant memories after his one dose of Motrin and generous IV fluid replacement. He was hungry and his family was eager to take him home, relieved at the good news. His Pediatrician was likewise thrilled and agreed to see him in the office the following morning.

As I was preparing the discharge paperwork, the Radiologist called back to tell me that she had reviewed the CT scan again and noticed a retropharyngeal abscess that she had initially overlooked. Oops. That changes everything.

A retropharyngeal abscess is an infection in one of the deep spaces of the neck. An abscess in this location is an immediate life-threatening emergency, with potential for airway compromise and other catastrophic complications. Retropharyngeal abscess is almost exclusively a pediatric diagnosis. Most incidents occur in children aged 6 months to 6 years, with a mean age of 3-4 years. Since the advent and widespread use of antibiotics in treatment of URIs, incidence of retropharyngeal abscess has declined considerably, and it is now relatively uncommon.

Patients with retropharyngeal abscess present with constitutional complaints such as fever, chills, malaise, decreased appetite, and irritability. Patients may complain of sore throat, difficulty swallowing (dysphagia), pain on swallowing (odynophagia), jaw stiffness (trismus), or neck stiffness (torticollis). Patients also may complain of muffled voice, the sensation of a lump in the throat, and/or pain in the back and shoulders upon swallowing. Difficulty breathing is an ominous complaint that signifies impending airway obstruction. Patient history is not always straightforward.

Indeed. Neither is the workup.

The head CT scan was only questionably indicated in the first place, and it was fortunate that the retropharyngeal infection was visible on the brain scan at all.



(images courtesy of the link above...my patient's abscess was a bit more subtle)

Another Medblog List

Here is a list of 661 English-written medblogs ranked via a unique algorithm created by jan(at)medblog.nl:

MedBlogEN

Check it out! I guarantee you'll find some medblogs you haven't seen before.

h/t Jeffrey at monash medical student

7 Weird Facts About Me

Food Edition

1) My favorite snack is raw green bell peppers sprinkled with salt. But I hate the yellow ones. The red ones are OK.

2) I eat pickled jalapeño peppers right out of the jar. Trappey's are the best, because they are crisp, not mushy.

3) I love pistachios, cashews, walnuts, pecans, almonds, and especially hazelnuts. But not mixed into brownies or ice cream. Never, ever.

4) And I don't really like peanuts at all. But I like Snickers and Reese's Cups.

5) And yet peanut butter disgusts me. My little sister used to chase me around the house with it.

6) When I work nights, I live off Stouffer's frozen meals. But I don't bring them to work. I only eat before I leave for work and when I get home from work. Swedish meatballs and French bread pizza are my favorites.

7) I'm addicted to candy, but I'm trying to cut down. Bottle caps, Runts, Sweet tarts, Spree, candy cigarettes....I'm a candy freak. If you are too, then you'd better not go to this website. Don't say I didn't warn you.

And yes, I've bought the 24 count box of candy cigarette packs. Twice.

- thanks to glittergirl for the thought.

Laceration Trick?

I was a little disturbed by the "Tricks of the Trade" article in the latest installment of ACEP News.

The authors suggest placing a couple of absorbable sutures in selected wounds under tension, followed by the use of tissue adhesive. As you can see by the pictures, the initial outcome appears to be acceptable but certainly suboptimal in my opinion. Now I'm a huge fan of Dermabond, but I fail to see the benefit in this particular application.

If you are going to go to the trouble (and cause the patient the discomfort) of anesthetizing the wound anyway, why not take the time to finish the job properly? A neat row of closely-placed 6-0 or even 5-0 sutures would even out the tension along the wound and provide for better approximation in most situations. I disagree with the authors that suture removal in children is significantly traumatic enough to justify the apparently inferior outcome of this technique.

It might be useful on a less cosmetically-significant area, primarily as a time-saver. But who the heck uses catgut anymore? Anyone?

I thought their second suggestion of using a combination of steri-strips and tissue adhesive for gaping wounds was a much better idea. That avoids the drama of the shot and allows the Dermabond to be used in situations that otherwise would require sutures.

A Tale of Two Codes

In one shift....

An elderly patient who suddenly suffered a witnessed arrest at home (and who had an advance directive) was brought in already intubated by EMS after almost an hour of CPR/ACLS, reportedly in PEA. I fully intended to simply check for a pulse and call the code on arrival, but I thought I felt a thready pulse, so I looked with the ultrasound and sure enough, the heart was still beating. We worked on this patient for another half hour or so before our hearts finally gave up.

A youngish middle-aged woman with recently diagnosed widely metastatic breast cancer (including hemorrhagic brain mets) was brought into the ER for the new onset of unresponsiveness. She did not have a previous DNR order, and her family initially wanted "everything done." Instead of coding her, she was sent to the CT scanner where it was immediately evident that she would not survive more than a day or two even if the most aggressive interventions were performed. A long discussion with the family ensued, and she expired later that evening.

So we coded the elderly DNR patient and didn't code the youngish full-code patient.

Weird.

The Best Day Ever

Thank you, Tom Meents. You, sir, are a total badass.

While I'm sorry to say that my son is more of a Grave Digger fan, you are personally responsible for making my daughter breathlessly exclaim that this was the best day of her whole life. And for that I am eternally grateful. She'd never been to a Monster Truck event before, but now she's hooked, thanks mostly to you. You were simply amazing.

I watched tonight as you repeatedly punished your left front tire (purposefully, I suspect) until it became flat and ultimately ripped from its wheel. When you continued to aggressively execute jumps on only three wheels before finally plowing into the retaining wall to close the show, you gave all of us fans not only our money's worth but a memory that will last forever.

Congratulations on your victory. Maximum Destruction, indeed.

Your fan,

scalpel

(above are my photos from 2006; I forgot my camera this time)

The Inflatable/Deflatable Ego

Such a fragile thing it is, really.

One busy night, a patient's family member came up to me and said excitedly, "You took care of my Dad!" That greeting is always good for a quick adrenaline rush as a surprise bolus of fight or flight hormone is squeezed from the remnants of my overworked adrenal glands. I wonder if police officers feel that way when someone reaches into their pocket. Is he going to pull out his driver's license or a gun?

This time it was a false alarm, as the person cheerfully recounted how well his father's lip laceration had turned out. I remember him well....he had suffered a complete laceration through the upper lip as if someone had taken a scissors and snipped from the gumline almost to the nose. If there were a breeze, his face would have flapped in it. Nasty.

I really didn't want to repair it myself, but as is becoming the norm, the Plastic Surgeon wouldn't come in and nobody else would take the transfer. So repair it I did. I thought it turned out pretty well at the time, but I was afraid of leaving him permanently disfigured. As it turned out, all the Plastic Surgeon had to do was take out the sutures. That's really nice to hear.

Not five minutes later, a nurse came up to me and said, "Remember that girl last week that you sent home....."