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Patient advocacy: a baby’s life is saved

Ok, so now that I’ve given you a really good example of the dangers of VIPs bullying doctors, I will present the flip side of the coin: a good kind of patient aggressiveness.

A 10 month old baby was vomiting and febrile, and her new mom brought her in to the hospital for an evaluation. She was told that it was gastroenteritis (my favorite diagnosis of late) and that the baby would get over it soon enough. The young mother insisted that she knew her baby, and that the infant had never been this fussy and that there really did seem to be something more serious at play. Again, she received eye rolls from everyone from technicians to nursing staff to physicians. “New mothers are so histrionic,” everyone thought.

But as the evening wore on, the baby became fussier and fussier, and began scratching herself all over. The nurses came in and tied her chubby arms and legs down so that she wouldn’t tear her skin. The mom wrung her hands all night. The doctor went home, yawning and sure that the baby would be fine in the morning.

Several episodes of violent, projectile vomiting ensued, and the mother pleaded for someone to take another look. No one would listen, as the doctor had written in the chart that the baby had gastroenteritis, so that was what it was.

In the middle of the night, after the physician had gone home, the mom insisted that the nurses page him to come back to the hospital. The nurses initially refused, but the mother told them that she would personally make their night miserable if they didn’t comply. The annoyed physician came back to the hospital against his better judgment, and found the mother and baby looking far worse than when he’d left. In fact, the baby’s vitals were becoming unstable and her abdomen was quite distended.

The physician ordered an abdominal x-ray series. It showed an advanced intussusception and the belly was distended with gangrene. He knew that she was likely to die. He asked the mother if she wanted him to call the general surgeon (who had no experience with operating on babies) or if she’d like to take a chance and get the infant to an academic center in New York City that had a team of pediatric surgeons on call. Time was of the essence, but surgical expertise varied greatly between the two options. The mom could tell that the physician was terrified, and her instincts told her that she should get the most experienced doctor to operate on her baby.

A few hours later, the baby was rushed into the O.R. at Columbia Presbyterian Hospital. The pediatric surgeon on the case told the mother that it was unlikely that the child would live, but that he promised not to give up on the baby. At that point, the baby was septic and seizing.

In a truly miraculous turn of events, the surgeon was able to resect the dead bowel and save the baby’s life. If the baby had arrived even a few minutes later, she probably wouldn’t have made it.

So in this case, I applaud the mother for being persistent and forcing the medical staff to take a closer look at this “gastroenteritis.” In our imperfect medical system, patients and families must sometimes advocate for themselves in order to get the attention they require. This story, in particular, means a lot to me, because I still bear the abdominal scar from the surgery.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

VIP Syndrome – a no-win situation

In my last post I described how VIPs don’t necessarily get better medical care. In this post I will describe a case study of a bully whose behavior wasted endless resources and time. This is a true story.

The son of a business tycoon experienced some diarrhea. He went to his local emergency room immediately, explaining to the staff who his father was, and that he required immediate treatment.

Because of his father’s influence, the man was indeed seen immediately. The physicians soon realized, however, that there was nothing emergent about this man’s complaints. After several blood tests and a stool sample were taken, he was administered some oral fluids and monitored for several hours, they chose to release him to recover from his gastroenteritis (stomach flu) at home.

The man complained bitterly and said that he wanted to be admitted to the hospital. The physicians, with respect, explained that he didn’t show any signs of dehydration, that he had no fever, his diarrhea was indeed fairly mild (he had only gone to the restroom once during the hours of his ED visit – and that was when he was asked to produce a stool sample). The man’s pulse was in the 70’s and he had no acute abdominal tenderness.

The man left in a huff, and called his father to reign down sulfur on the ED that wouldn’t admit him.

And his father did just that.

Soon every physician in the chain of command, from the attending who treated him in the ED right up to the hospital’s medical chief of staff had received an ear full. Idle threats of litigation were thrown about, and vague references to cutting key financial support to the hospital made its way to the ear of the hospital CEO.

The hospital CEO appeared in the ED in person, all red and huffing, quite convinced that the physicians were “unreasonable” and showed “poor judgment.” Arguments to the contrary were not acceptable, and the physicians were told that they would admit this man immediately.

The triumphant young man returned to the ED for his admission. Since the admitting diagnosis was supposedly dehydration, a nurse was asked to place an IV line. The man was speaking so animatedly on his cell phone, boasting to a friend about how the doctors wouldn’t admit him to the hospital so his dad had to make them see the light, that he moved his other arm just at the point when the nurse was inserting the IV needle. Of course, the poor woman missed his vein.

And so the man flew into a rage, calling her incompetent, cursing the hospital, and refusing to allow her to try again.

At this point, the ED physicians just wanted him out of the emergency room – so they admitted him to medicine’s service with the following pieces of information on his chart:

Admit for bowel rest. Patient complaining of diarrhea. Blood pressure 120/80, pulse 72, temperature 98.5, no abdominal tenderness, no white count, patient refusing IV hydration.

Now, this is code for: this admission is total BS. Any doctor reading these facts knows that the patient is perfectly fine and is being admitted for non-health related reasons. With normal vital signs, and no evidence of dehydration or infection, this hardly qualifies as a legitimate reason to take up space in a hospital bed. And when the patient is refusing the only treatment that might plausibly treat him, you know you’re in for trouble.

The man was discharged the next day, after undergoing (at his insistence) an abdominal CAT scan, a GI consult, an ultrasound of his gallbladder, and a blood culture. His total hospital fee was about $8,000.

Do you think he paid out of pocket for this? No. He submitted the claim for payment to his insurance company. Their medical director, of course, reviewed the hospital chart and realized that the man had no indication for admission, and refused medical care to boot, so he denied the claim.

So the son appealed to his father, who then rained down sulfur on the insurance company, threatening to pull his entire business (with its thousands of workers insured by them) from the company if they didn’t pay his son’s claim.

The medical director at the insurance company dug in his heels on principle, assuming that if he continued to deny the claim, the hospital would (eventually) agree to “eat the cost.”

In the end, the insurance company did not pay the claim. The CEO of the insurance company called the hospital CEO, explaining that it was really the doctor’s fault for admitting a man who didn’t meet admission requirements. The hospital CEO agreed to discipline the physician and eat the cost to maintain a good relationship with the insurance company that generally pays the hospital in a timely manner for a large number of patient services.

I ask you, my friends, does this seem fair? It’s because of these cases that doctors become (sadly) hard of hearing when it comes to patients who appear well, but may indeed have a serious condition.

In my next post, I will describe a true story of a baby whose life was saved because of her mother’s insistence.

P.S. There are many comments on this post, featured at Kevin MD.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Do VIPs get better medical care?

People often believe that the medical treatment that VIPs get is far superior to the care received by “common folk.” While it’s true that a VIP might get a nicer hospital room, the care received might actually be inferior.

Why? Because all of the anxiety and pressure to perform all possible tests to rule out all possible problems results in higher risk to the patient. Most tests are associated with some degree of risk – catheter infections, phlebitis, dye alleries, anesthetic reactions, and so on. Though these risks may be small, they are additive.

Beyond the risk of unnecessary tests, is the risk of unnecessary medications. When a VIP complains of an issue, he may get additional medicine. Medicine has side effects, and side effects can have serious consequences. Consider the deadly side effects of pain medicine that a dear patient of mine once had.

Then there’s the pressure that physicians feel to do what the patient requests, rather than exercising their clinical judgment.

In one particular case, a young executive came to the ER complaining of abdominal pain. The physicians ran all kinds of tests and concluded that he had a common stomach virus. The man was convinced that he had appendicitis and called in a favor from his “connection” who knew the CEO of the hospital. The hospital CEO questioned the physicians taking care of the man – whether they could say with 100% certainty that this wasn’t appendicitis. They said that it was highly unlikely, but that the only way to be 100% certain would be to remove the appendix and examine it under a microscope. The CEO asked them to take the patient to the OR. Of course, the executive did not have appendicitis. He did, however, undergo an unnecessary surgery, which his insurance company paid for in full, contributing to potential increased premiums for the others in his company’s group. Did this VIP get better care? I think not.

In my next post I’ll discuss how one VIP bullied his way into the hospital without even being truly sick, causing all kinds of problems that dragged on for months!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Medicine’s real language barrier

A Turkish friend of mine told me that he had saved for several years to bring his grandmother to America for a visit. His pre-teen son had met her only twice in his life (via trips to Istanbul) but they corresponded frequently and had a very close bond. My friend said he wanted to surprise his son by having his grandma at home when he came back from school on his 14th birthday. The only hesitation, my friend said, was that his mom didn’t speak any English and he was worried that she might get lost during an airplane transfer or in the airport. He worried that she would be afraid and alone.

Being in a foreign country where you don’t speak the language can be a frightening experience. When I was a teenager, I flew to Zaragoza, Spain to visit a friend of my mother’s. I felt excited at take off from the US, but as the plane approached the unfamiliar red soil of our destination, a sense of uneasiness settled in. The flight attendants started messaging in Spanish, and as we touched down I knew that I wasn’t home anymore. All I knew how to say was “hola.”

As I made my way through the airport, all the signs were in Spanish, I knew I needed to get a cab, but I wasn’t sure where to wait – and the Spaniards didn’t seem to respect queues. Once I fought my way to the front of a gaggle of natives, I realized that the cab driver needed to ask me clarifying questions about my friend’s address. I responded in English, to which he repeated his question with increased volume. I felt really stupid and quite helpless.

My experience was kind of similar to the feeling that patients have when they are thrust into a medical situation with a sudden, life threatening illness. Healthcare professionals can forget how foreign everything is to the patient, and go about their activities without explanation, or with jargon-rich “medicalese” that is virtually inscrutable to the person with the illness. When questioned, they repeat the jargon, raising their voice for emphasis and “clarity.”

Hospitals spend lots of money on translator services for foreign languages, but many healthcare professionals forget that medicine itself is a kind of unique language that requires translation. As the consumer driven healthcare movement takes wing, it will be more and more important to provide a kind of translator service for those who need to make educated decisions about their medical options. The accuracy of the translation can be a matter of life or death, and so healthcare consumers need to be very selective in where they get their information. Considering the source of your information has never been more important. Don’t let your health be lost in translation.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The art of being different – a girl scout’s story

Girl scout cookie season is upon us, and recently our office was swarming with youngsters taking cookie orders. I wasn’t sure which girl I should order from (one can’t really order from each of them and expect to maintain any semblance of a normal BMI) and as I was considering how to choose, one energetic little girl simply walked right up to me and asked if I’d like some cookies.

She was slim and blonde, with bright eyes and an honest face. I knew the “sales pitch” didn’t come naturally to her, and I tried to make it easier by joking a bit. She was shy, but on a mission. I asked her which type of cookie she liked best, and if her daddy ate too many of them. She was innocently pleased with the interaction and disappeared down a hallway near some cubicles.

Many weeks later a large delivery of girl scout cookies arrived. There was a mass distribution strategy in place with moms and girls cutting open cardboard boxes of cookies and delivering them to buyers. I asked if my cookies were on the list. They told me that they didn’t sell me the cookies, so I’d need to wait for the specific little girl who sold them to me to stop by.

About a week later, when I had assumed that my little girl scout had forgotten about my order (and the rest of our staff had well and truly gorged themselves on thin mints), her dad came into my office with a pretty bag tied with a ribbon and a hand written card from his daughter. He told me she asked him to deliver it personally, because she wanted her service to be different than the other girls. Her dad joked that he was trying to train her about “differentiators” but I was quite touched by the effort she had made to make me feel like a special customer.

Later that afternoon I sat down to write a thank-you card to the girl. I wanted her to know that her efforts made a difference, and that I noticed her hard work in making my cookie purchase a personalized experience (not just part of a bulk delivery service). I put some stickers on the card, I used colorful paper, and a big red envelope.

A few days later I asked her dad if she liked the card. This is what he wrote to me:

“She loved it. She saw it at breakfast and came screaming upstairs to show it to everybody. Thanks!”

That really made my day. I hope in some way that I’ve encouraged this little girl to continue to reach for excellence, to stand out in the crowd, and to know that her work is appreciated. It is this sort of attitude toward life that will help her grow up to be… a revolutionary.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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