Dead with a grin on your face

Happy patients are not always better patients.  Patient satisfaction has been a source of debate for a long time.  More and more hospital administration is pushing for better patient satisfaction.  Satisfaction is based more on the patient’s perception of how they were treated not how well they were treated medically.  Many times the medical providers’ pay and job are related to how the patients fill out the survey.  It is kinda like the patient giving their waiter a tip at the restaurant.  It does not necessarily reflect how good the food was, instead it reflects how well I kept your glass full.  I agree that people should not be rude and should keep their patients informed about what is going on.  But what about when the patient gets mad because I will not send them home with narcotics when they are a known drug abuser or when a mom demands her kid get a head CT because he just got hit in the head with a wet noodle despite all the risks of radiation and possibility of cancer?  Just like your car dealer, we are graded on the patient’s satisfaction where anything less than a 5 out of 5 is failing where 5 is outstanding, way above average.  Looking at this grading expectation, it is fundamentally flawed.  By definition, 50% of clinics/doctors/hospitals cannot provide above average care.  So why are they penalized for not being able to do the impossible?  Recently there was a study (link included below) which had an interesting finding. It concluded: “In a nationally representative sample, higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.” Go to the actual article for more interesting info.  Looking at it a different way from the same data, people who were not satisfied with their care had less money spent on them, less tests performed, and did better.  This just shows that many times patient satisfaction is bought not earned.  I could do the best thing for the patient and they do great.  But they are still unhappy because they thought they needed a pain medications or a certain test and did not get it.  More is not always better.

The Cost of Satisfaction A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality

Arch Intern Med. 2012;172(5):405-411

Ummmmm.. Detergent

Everyday we have to worry about something else. Retail world only makes it tougher. Toy guns look to real. Cleaners look like kool-aid. Prescription drugs look like skittles or M&Ms. Now it is the detergent.

New Detergent Pods Pose Poisoning Risk


Laundry detergent makers have introduced miniature packets in recent months. Doctors warn that the brightly colored packets may pose a hazard to children.

Laundry detergent makers have introduced miniature packets in recent months. Doctors warn that the brightly colored packets may pose a hazard to children.

Childhood poisonings from a new type of detergent packet have soared in recent weeks, experts say, with the total climbing to more than 1,200 this week from about 200 in late May.

Health authorities have been concerned since late March, when poison control centers around the country noted a small number of reports from parents whose children had opened and swallowed the brightly colored laundry detergent products, which are small enough to fit in a child’s palm and may be mistaken for candy. The detergent packets were introduced by a various companies over the winter as a convenience that can be easily dropped into a washing machine.

But because of their bite-size shape and candylike colors, many toddlers and small children have been eating them. Poison control centers first starting putting out alerts about two to three months ago, not long after the products were introduced in the United States. By late May, the number of reported cases had reached 200 to 250 nationwide, prompting widespread news media attention and an announcement from Tide, which makes one of the most popular forms of the products, that the company would change its packaging to make the packets more difficult for children to tamper with.

Still, poison control centers say they continue to see more and more cases. This week, the California Poison Control System announced that at least nine small children in that state were taken to emergency rooms between Saturday and Tuesday after exposure to the packets, bringing the state’s total number of cases to at least 91. Six of the latest cases in California involved Tide Pods. Two were linked to Purex Ultra Packs, and one involved All Mighty Paks.

According to the latest figures, poison centers across the country have been seeing an average of 10 cases a day, and as many as 28 a day, said Bruce Ruck, assistant director of the New Jersey Poison Information and Education System. All told, there have been at least 1,210 cases reported to poison control centers this year. None have been fatal, but a number of cases have been severe. At least 11 children have been placed on ventilators, and 10 have been intubated.

“We just had a really bad one the other day here in New Jersey, with a kid who ended up on a ventilator,” Dr. Ruck said. He noted that some of the cases have involved damage to children’s eyes, which may occur as children bite into the packets.

Poison experts are not sure why so many cases have been so severe. Compared with traditional powder and liquid detergent, the newer detergent packets and pods seem far more toxic. Children who have bitten into them have suffered severe nausea and vomiting, respiratory distress and metabolic abnormalities.

“The regular detergents that have been around forever don’t appear to cause the same problems, and we don’t know why,” Dr. Ruck said. “We don’t know yet what’s different about them. They’ve only been on the market a short period of time.”

In an interview, a spokesman for Tide said the company’s newer, more secure packaging should hit stores next month. But he also emphasized that like any household cleaning product, the detergent pods should be kept out of the reach of children.

Dr. Ruck warned that parents need to do more than just put these products out of the reach of children. “One of the things we’re trying to get across to parents is to not just put these up high, but to put them up very high in a locked cabinet,” he said. “You don’t want to store these on top of the washing machine or dryer, because kids will stand on chairs to get stuff. Children will find a way to get into everything.”

The unsung heros

By now I am sure all of you  have heard about the shooting in Aurora, CO.  It is a terrible tragedy.  The police at the situation did an outstanding job taking care of the injured.  Placing patients in their squad cars and taking them to the hospital was a great choice.  Sometimes waiting on the ambulance is not the best choice.  There are 2 schools of thought about transporting sick patients.  Scoop and run vs stay and play.  I am an advocate of scoop and run.  This has been done for a long time by the “ghetto ambulance”. The ghetto ambulance is a buddy of the guy who got shot throws the guy in the car.  Once he gets to the hospital driveway, he starts honking his horn to get people to come out.  He kicks the guy out the car door and then takes off.  This gets the victim to the hospital quicker (most of the time) than EMS because they do not have to wait for the ambulance to get there.  Those officers that took the patients to the hospital did a great job and probably saved many people’s lives.

I had been watching the news to see if they ever talked about the staff at the hospital and what they did for the victims.  I have not heard anything.  This situation is what we train for but at the same time it is our worst nightmare.  It is also in this instance that the ER does what it was meant to do.  This was a true disaster situation for the hospital.  An ER (that was probably already full) is now deluged with 70+ trauma patients of unknown condition.  Trying to put myself in the situation of the docs on that night…  At almost 1am, I would be hoping the ER was going to slow down soon.  Then all of a sudden you hear that pretty much all the ambulances have been dispatched to the local movie theater.  Details would be hearsay.  My first thought would be “Oh crap.” Followed by a long sigh.  Then I would start trying to think what could have happened.  I have to start going into disaster mode.  Was it a gas, a wreck, a poison, a shooting??  We would start to try to clear out some of the critical rooms to put the patients.  Then the first police car would arrive with patients.  Go pull the patient out and go to work.  This scenario sends shivers down my spine – some of fear and some of excitement.  This might be overwhelming chaos but this is why I got into the business.  Take care of patients that out number your resources.  This is a style of “McGyver medicine”.  I love McGyver medicine.  Today’s post is a big “Thank You!” and a lot of appreciation for the stellar job done by the local hospital, EMS, and police. 

Hey Kids, let’s go play in the ER waiting room

Just a normal day in ER. Rooms are full. Waiting room is full. I am not happy. The nurses aren’t happy. The patients are not happy. No one is happy. Our ER sees about 35,000 patients a year. It has only 10 actual beds. The waiting room has enough chairs for about 25 patients. As you can tell, things can get a bit crowded in the waiting room. It is usually a pretty tense place to be. I will quickly admit the waiting room is scary. I control pretty much what goes on in the back. But the waiting room, that place is pure chaos. People yelling, kids screaming, drunks a sleep on the floor. Kids trying to find a place to play or do something to occupy their time. People always coming in and out. In the background, you have Jerry Springer on the TV. I do not know why Jerry Springer is always on that TV. Maybe it is because the people in the waiting room don’t want to miss the episode that features their daddy who is also their brother. Or maybe they are wanting the number to call in so they can get on… I don’t know…. But today I saw something extraordinary. A diabetic lady checked in with an infection on her leg. She was brought back to get vital signs. Her vital signs were normal but the leg infection was actually oozing this yellow green pus that was about the consistency of BBQ sauce. It was wrapped in paper towels and scotch tape. The pus had already drenched the towels and was oozing on the floor. Because we had no beds the patient was taken back out to the waiting room without the wound being redressed (that was our bad). Patient then waited in the chair for her name to be called when a bed was ready. The ooze began to pool and spread on the once off-white tile. It was to the point you would actually have to make a special effort to step over it. The next thing you know. 3 kids are sliding around in the ooze like it was a slip and slide. They would get up dripping wet from the waste down in this yellow green bodily fluid and then do it again. They were having a ball. They thought it was awesome. Nothing like an indoor water park in the waiting room. Please bathe all your children – who knows what they have been playing in.


Today I was taught how to use our hospital’s electronic medical record “meaningfully”.  This is interesting since I have been using electronic medical records (EMR) for 6 years now at multiple facilities for doing my patient’s notes, placing orders, writing scripts, and giving discharge instructions.  But now I have to use it meaningfully.  This all stems from the stimulus packaged and the Feds trying to get everyone to adopt electronic records.  Our hospital got multiple millions of dollars from this.  One of the big requirements for us to get the money is to do “meaningful use” with our EMR.  Is the money to help us further our meaningful use?  No.  Instead “meaningful use” is the hurdle we must jump and keep on jumping so we can get the money to spend on projects not related to EMR.  It is like your mom telling you to go jump over a fence so you can get your dinner.  Does jumping over the fence having anything really to do with getting dinner? No, it is just  a random unrelated hurdle imposed by an authority figure.  Meaningful use does the same thing.  The definition of “meaningful use” was set by CMS and is very nebulous.  On a side note, nebulous is my word of the day.  I seem to be using it everywhere today and I do not know why.  Ok back on track.. To meet the requirement for meaningful use, I have to click 4 buttons.  One to say I reviewed and “reconciled” a patient’s medications, one for allergies, another for their past medical history, and one to say I gave the patient a piece of paper listing the medications the patient just listed for me.  On the surface, this is great.  I should be looking at all this.  The funny part is – I have always done this and so has almost every other provider who does their job well.  But now I have to make sure I click these buttons to say I did something that I already said I did in my note.  And if I don’t we do not get the money and then could be punished.  Again this is just another example of a useless requirement that has never been shown to improve patient care and I doubt ever will.  But it does justify someone’s job and another government agency’s existence.

By the numbers

Definitely some interesting numbers.

The U.S. Supreme Court’s healthcare ruling on Thursday has far-reaching implications for a healthcare system that, according to the Paris-based Organization for Economic Cooperation and Development, is highest in spending but just 31st in providing coverage to its people among the OECD’s 34 members.

The following information ranking the United States by category against the OECD’s other members comes from the November publication "Health at a Glance 2011 – OECD Indicators."

– 1st in Spending – Annual healthcare spending totals $2.6 trillion, equal to 17.9 percent of U.S. annual gross domestic product, or $8,402 for every man, woman and child.

– 1st in Good Health Self-Assessments – 90% of U.S. adults aged 15 and older describe themselves as being in good health versus an OECD average of 69.1%.

– 1st in Obesity – More than one-third of American adults are obese, up from 15% in 1980.

– 2nd in Prevalence of Diabetes – 10.3% of the U.S. population suffers from diabetes, surpassed only by Mexico’s 10.8%. The OECD average is 6.5%.

– 3rd out of nine in Waiting Time for Specialists – Out of nine countries from Europe, North America and Australia and New Zealand, the United States has the third shortest waiting time for specialist appointments at 20 weeks; Germany and Switzerland had shorter waiting periods.

– 4th in Preventing Death from Stroke – The United States ranks behind Israel, Switzerland and France with 32 stroke-related deaths per 100,000 people.

– 7th in Cancer Incidence – Cancer afflicts more than 300 people per 100,000 in the United States, compared with an OECD average of 261 per 100,000.

– 9th in Preventing Death from Cancer – At 185 deaths per 100,000, the United States is well above an OECD average of 208 per 100,000.

– 10th in Number of Practicing Nurses – 10.8 per 1,000 population versus an OECD average of 8.4 per 1,000.

– 11th of 11 in Unmet Need for Care Due to Cost – The United States ranks last among 11 OECD countries in its ability to provide affordable care: 39% of people with below-average income and 20% of people with above-average income report foregoing a doctor visit or prescription because of the cost.

– 25th in Preventing Death from Heart Disease – At 129 deaths per 100,000 people, the U.S. heart disease mortality rate is below an OECD average of 117 per 100,000.

– 27th in Life Expectancy – Americans can expect to live 78.2 years on average, below the OECD average and just behind Slovenia and Chile.

– 29th in Number of Practicing Doctors – The United States has 2.4 practicing doctors per 1,000 population, placing it below an OECD average of 3.1.

– 29th in Doctor Consultations – At 3.9 annual doctor visits per capita, the United States leads only Ireland, Mexico, Sweden and Chile versus an OECD average of 6.5 percent per capita.

– 30th out of 39 in Hospital Beds – 3.1 per 1,000 population.

– 30th in Medical Graduates – 6.5 per 100,000 population, ahead of only France, Japan and Israel. The OECD average is 9.9 per 100,000 population.

– 31st in Health Coverage – An estimated 81% of Americans are covered by private or government health insurance, placing the country ahead of only Turkey, Mexico and Chile; 25 OECD countries cover 99% or more of their citizens.

– 31st out of 40 in Infant Mortality – 6.5 babies die per thousand live births in the United States, placing the country behind Poland and the Slovak Republic and below an OECD average performance of 4.4 per thousand live births.

– 31st in Preventing Premature Death – The number of years lost in the United States to premature death is surpassed only by Hungary, Mexico and Russia. The main causes are accidents, violence, cancer and circulatory disease.

The OECD was established in Europe after World War Two to promote peace through cooperation and reconstruction. Its members are Australia, Austria, Belgium, Canada, Chile, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Luxembourg, Mexico, Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Slovenia, South Korea, Spain, Sweden, Switzerland, Turkey, the United Kingdom and the United States.


A man made up of boxes

I watched “Act of Valor” last night.  The men, women, families, and friends that serve our country are worthy of our utmost admiration due to the sacrifice that they make to protect us.  In regards to the movie, there were a couple quotes that got me thinking about how they relate to medicine especially emergency services (firefighters, police, EMS, Emergency Room personnel).  I have included the quote below.

“Put your pain in a box — lock it down; like those people in those paintings your father used to like. Real men, made up of boxes — chambers of loss and triumph of hurt and hope and love. No one is stronger or more dangerous than who can harness his emotions — his past.”

This is very true for us that work in Emergency Services.  I know that in the ER I am expected to do this.  The scariest part is that I can do this quite well – maybe it is a talent or a curse or both?  I have pulled a lifeless 9-year-old from her uncle’s arms.  She had been shot through the chest.  The team and I intubated her and then cracked her chest.  We got her back and then lost her.  This was repeated 3-4 times until we could not get her back again.  I have intubated, placed 2 IOs, shocked and then pronounced dead a 3 month old boy.  I have opened a mother’s chest who lost pulses in front of me after being hit by a car only to pronounce her 1 hour later.  I have tried to comfort families that have just lost their dad, mom, or child.  I have ducked a punch of a hysterical brother who just lost his sister.  I have called the cops on a father who just killed his kid because the kid spilled some milk.  These are just the ones off the top of my head. I have saved many more than I have lost, but the ones that I have lost are the ones that really stand out.   It is the lost ones that follow you.  Saving people is what I am supposed to do.  Loosing them is failure – in a way.  I know that I could not have done anything else and that I did my best and at times did more than someone else in my shoes would have done.  But that does not make me feel any better.

In this line of work, you are supposed to “lock it down” and see the next runny nose (who is mad because they have been waiting so long) like nothing happened just a few short minutes before.  Because if I don’t lock it down, I will not be on the top of my game for the person who comes through my doors.  I cannot think about it. I cannot dwell on it.  I do my job and just keep on going.  That is our life in Emergency Services.  We put our losses, triumphs, hopes, and success in locked boxes so that we can be strong for the next person who needs us.