Cutters

From the Self Injury Community Forum:

"I haven't cut in about two weeks and i'm going ok, but i constantly find myself thinking about it way more often. But i have had self control, up until now...

Today though, we had art class and we are doing smth to do with carving and we use a tool that is really sharp [and it cuts real well, i've tried it].

So I was sitting there looking at them [it is a set of 5] and i just wanted to cut, i needed to so badly but i was thinking i can't do it now, everybody can see me...

So i got away with it this time, but i'm afraid that later today, especially when i'm in the bathroom, i will give in and i don't want to...

Actually, i don't know what i want..."

Wow. There's lots more where that came from.

Sunday Afternoon Snails

Confessions of a Drug Addict

...to The Angry Pharmacist:

"I would like to explain some stuff to you from the addicts point of view. It's a growing problem, prescription pain killer addiction. I blame everyone for this. It's not 100% the addicts fault.

Maybe put some blame on the MD's who get the person addicted by giving high doses of the pain meds, and give refills and believe the crap about them losing their script, and losing their meds and so on, vacation refills. Blame should be placed on the ER who treats the seeker with more morphine/demoral/dilaudid, they know he/she is an addict, their [sic] there 3 x a week with a migraine, but yet they give the pain meds. The insurance company who keeps authorizing the refills."

Read the rest.

Most Americans Oppose Healthcare Reform

From Professor Bainbridge:

"One of the real problems with the debate over health care reform is that the squeaky wheel gets the grease. The media and the politicians focus on people who have problems with health care issues, such as the uninsured, the underinsured, and those whose insurers deny coverage for significant health care problems. The trouble of course is that lots of people are satisfied with their healthcare."

In fact, most Americans are satisfied with their healthcare:

"Gallup's annual Healthcare survey, conducted Nov. 11-14, finds 57% of Americans saying they are satisfied with the total cost they pay for their healthcare, while 39% are dissatisfied."

An overwhelming majority of Americans say that the quality of healthcare they receive is either good or excellent (83%) and say the same about their own healthcare coverage (70%).

The good professor goes on to quote Jay Reding:

"Universal health care has a basic and fatal flaw, you can’t simultaneously reduce the cost of a service and increase access to it. If you have universal access, you have to find a way of paying for people to get that access, which raises costs. If you want to keep costs down you can only economize so far before you have to restrict access. Universal health care is a bit like a perpetual motion machine—it would be wonderful in theory, but it can’t actually exist in reality...

When confronted with a plan that forces people to change their coverage—and not necessarily for the better—it’s not surprising that the theoretical support for universal coverage ends up losing to the desire not to lose what people already have."

Read the whole thing.

The Nutty Buddy

Discussion here
h/t Instapundit

Even funnier clip below:

My Thoughts on Tier 4 Medications

My thoughts on tier 4 medications are somewhat different than some of my colleagues, I suppose.

As a compassionate physician, I too want my patients to have the best care possible, and I too hate seeing people suffer. But if we as a society are going to try to provide a broad variety of services to patients, whether it be under a shared-risk insurance pool, a socialistic government model like Medicare, or any other method imaginable, then costs are going to have to be controlled somehow.

By forcing individuals to share some of the expense of certain extremely expensive medications, our ability to continue to provide medical care to the masses can be maintained at a more reasonable cost. If patients want to purchase insurance that covers a complete formulary of expensive medications with only a minimal copay, then they should be able to do so, paying substantially more for the opportunity. Of course waiting to buy such insurance until they need a certain medication isn't going to cut it. You buy insurance to insure against disasters; once you already have cancer, multiple sclerosis, or rheumatoid arthritis, the levee has already broken and the water is rising. If patients want to reduce their monthly cost of health insurance, then they should be able to choose a policy that either requires high copays for certain medications, or save even more by choosing an HSA.

Medicare is different issue altogether, because it's not really insurance. It's more like a defined benefit plan with broad (essentially universal) eligibility. The only ways such a plan can stay within budget are to either raise rates (taxes) on everyone or to reduce benefits. Would it be preferable to raise the Medicare eligibility age from 65 to 70? I think that should happen too, but I suspect that concept won't be received very well either. This tier 4 pricing scheme is a way to maintain benefits while only raising rates on the users of the drugs in question. Brilliant, I say.

"But why should pharmaceutical companies charge so much for these medications?" you might ask. If these companies were denied the opportunity to profit from their research and development, then they wouldn't be bringing as many new products to the market. I think pharma companies should be allowed to reap the rewards of their research; if you take away the incentive to create new and improved products, then there won’t BE as many new and improved products. If patients were forced to settle for methotrexate instead of Remicade and repeated transfusions instead of Epogen, life would still go on.

Would it be a better life than what we have now? No.

Socialism and price controls on business just don't work well. Never have, never will.

The Rash Doctor

A very healthy-looking young man presented to the Emergency Department with a rash that had been bothering him for three months. Yes, that's months: as in three complete cycles of the moon.

Not being much of a rash doctor and finding no evidence of impending doom on the rest of his examination, I gave him a couple of possible diagnoses and prescribed some standard ER rash therapy for him until he could get an appointment with a Dermatologist.

"You mean to tell me you don't know what's causing my rash?"

Well, I have some ideas, but the bottom line is that I don't think it's one of those rare and dangerous rashes that you might have read about in the newspaper. It's basically just a nonspecific rash as far as I'm concerned, not likely to cause you any harm. But you should try this cream, schedule an appointment with a Dermatologist, and I'm sure that if the rash is still bothering you by the time you get an appointment then the rash specialist can figure it out.

"But I don't have insurance, and I bet that Dermatologist visit will be expensive."

Compared to an ER visit, not so much.

God Help Me

My son became a teenager today.

Somewhere my parents are laughing.

Joe Snow

A paramedic gave his life in the line of duty. A touching story from Musings of a Highly Trained Monkey.

The Hypocrisy of Overbilling

In the ER the difference between charging a 99284 and a 99285 is the addition of a family or social history (which can be as simple as "lives alone," or "nonsmoker," but not necessarily both). That one line is completely irrelevant to my medical decision-making, but increases my payment significantly. A similar situation occurs with inpatient admissions and consultations; if the useless family history is omitted, the physician's payment is reduced.

Is billing for questionably-indicated procedures really any different than adding an unnecessary family or social history to increase one's charges? I say no. If I don't need to use the social/family history in order to make an accurate diagnosis and disposition, then I'm essentially overcharging just the same as a Cardiologist who orders a questionably-necessary echocardiogram. We play these tricks because the government doesn't pay us what we think our services are worth.

The Happy Hospitalist sees it differently, and we are having an interesting discussion in his comment section. What say you?

Nurse vs. Patient

Recently, we were presented with a typical frequent-flying crackhead who had the usual litany of complaints. The specific details don't really matter; I'm sure you know the type. Apparently one of the nurses on duty had some previously unpleasant experiences with this particular individual, and she seemed none too thrilled about her assignment. I, on the other hand, had never seen the patient before.

This patient was a bit irritable and paranoid, but there was neither obvious evidence of danger to self or others nor anything particularly abnormal on the examination. As I was charting my notes, I could hear some animated discussion coming from the room. The nurse was finally able to obtain some blood, but she was unable to start the IV. After I reviewed some of the previous records, I decided that I didn't necessarily want this patient to have an IV anyway, because I saw that on a previous visit the patient had eloped from the ER prior to disposition. So I ordered an IM injection of a sedative, which the patient agreed to accept, grateful that there would be no more IV attempts.

But the patient didn't want the nurse in question to give the injection, because the patient was now afraid of her. She tied the tourniquet way too tight on purpose, the patient claimed, and she was less than gentle with her multiple IV attempts, purposely "jabbing the needle into the bone." Unfortunately I still had a few other patients to see, and I really didn't have time for any nonsense. Whatever, I'll try to find a different nurse to give you the shot.

"Oh no you won't!" barked the clipboard-carrying nurse administrator who had been lurking vulture-like, eager to plunge her beak into the carrion this situation was becoming. "This nurse is assigned to the patient, and she is the only nurse that will be involved. The patient isn't allowed to change nurses, especially after being so abusive and uncooperative all these times. We're not going to play these games."

Fine, I said. I don't care who gives the shot, or really if the patient ever even gets the shot. It's not really an emergency anyway. I'm just waiting on the blood tests and trying to make the patient a little more comfortable and less agitated so everyone can chill out a little bit.

Of course the patient refused the shot from the "mean nurse" and continued to be angry and upset. A battle of wills ensued, in which each of the opponents tried to exert their dominance over the other. The patient used whatever ammunition was available, primarily the power to hit the call bell and to be generally defiant and rude. The nurse countered with her unwavering authority and adherence to policy. For example: the patient was claustrophobic and wanted the door to the room open. The nurse took it upon herself to be the door Nazi and kept closing the door, smugly quoting government regulations and patient privacy considerations.

Was this nurse really such a true believer in the closed door policy that she consistently applied it to all patients in every situation? No, she was just using the policy as a stick with which to poke this particular patient. There were some raised voices from both corners and a couple of visits from security, but nothing really exciting or disturbing. After they eventually tired of the battle, the nurses came to me for resolution of the problem.

"What are you going to do about this?" they asked.

My job is to diagnose and treat emergency medical conditions. Based upon my initial assessment, I determined that some tests were indicated, and my disposition will be based upon those results. If the patient wants to stay and be treated, then we should treat the patient. If the patient wants to leave, then I'm not going to stand in the way. I've got a couple of sick patients I'm dealing with right now, and the fact that this patient is annoying and doesn't want to follow your rules isn't high on my list of priorities at the moment. I'm not going to do anything that would make this situation more unpleasant than it already is, if that's what you're asking. I've been in that room three times, and I've been able to verbally calm the patient down each time. I recommend that you try to do the same instead of agitating the patient further.

I'm all about supporting nurses, but I will never support their blind adherence to bullshit policies and regulations, and I don't like it when they seem to purposely antagonize patients. I admit that I'll probably be less inclined to tolerate any misbehavior from this patient after a couple more visits like this one. But in this case, I couldn't shake the feeling that we all could have handled the situation better.

UPDATE: IF you want to know more about crackheads AND you need a laugh THEN go here ELSE die.

Six Word Memoir

My six word memoir:

Don't mistake my equanimity for apathy.

My second choice was "memes were made to be broken." But when Monkeygirl asks you to do something, you just do it.

Foreign Body Removal from the Ear

I recently treated a young patient with a cylindrical metallic foreign body in the ear canal (no, it wasn't a battery - it was a tiny fuse). The smoothness and rounded edges of the object made grasping with alligator forceps impossible. The width of the object prohibited the use of a cerumen spoon since the object fit the canal almost perfectly. The only magnets we could find were the weak EMS advertisements on the refrigerator, and my lame attempt at using a suction catheter was entirely ineffective. Because I couldn't tell how close the object was to the eardrum, I chose not to attempt the balloon-tipped catheter method in which a small catheter is advanced past the foreign body and a small balloon is inflated, allowing removal of the object as the catheter is withdrawn.

Ultimately I tried irrigation, but since I've not heard this specific technique used before, I thought I'd report it. I removed the object by irrrigating with Auralgan.

Auralgan is a topical anesthetic which also contains glycerine. It's a thick solution that is quite viscous yet also very slimy. Using a 5cc syringe and a 20g angiocath, I directed the tip of the catheter at the edge of the object. Apparently there was just enough room between the ear canal and the cylindrical object for the solution to pass by. The consistency of the Auralgan provided superior back pressure as well as excellent lubrication which made what was until then a frustrating procedure seem ridiculously simple. One small squirt and we were done.

If anyone else tries this (or has tried it before), let me know how it went.

Quote of the Day

"He's got to just stay to himself and swallow it ... because everybody wanna try the football player."

- Former NFL running back and Leavenworth inmate Bam Morris, on Michael Vick's incarceration in a federal prison for dogfighting (WARNING - graphic image).

Ick. I bet he misses his old gravy train.


(via ESPN)

Pizza Hut and Guns

I love Pizza Hut pizzas.

My favorite pie is their thin and crispy Pepperoni Lover's, but when I'm feeling a bit rebellious, I sometimes take a walk on the wild side and order a supreme. I enjoy their pan pizza too, and I've even been known to scarf down a few of their wings. I have wistful memories of the discontinued P'Zone.

Not a week goes by that I don't have a large order delivered for the family, and twice a week is not unheard of. When I buy pizzas for the ER, it's a safe bet that I'm calling the Hut as well. I'm a loyal fan, forsaking all other pizza delivery restaurants for over 20 years.

But I can assure you that if Pizza Hut eventually fires James William Spiers III for defending himself against an armed robber, I will join Iowa State Senator Brad Zaun, and I will never order another meal from that franchise ever again.

I urge you to do the same.

UPDATE: similar case here.