September 2nd, 2009 by Dr. Val Jones in True Stories
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This post is a “Dr. Val classic” – first published in early 2007.
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Internship, for those of you who may not know, is the first year of residency training. It is the first time
that a doctor, fresh out of medical school, has responsibility for patient care. The intern prescribes medications, performs procedures, writes notes that are part of the medical record, and generally learns the art of medicine under the careful watch of more senior physicians.
Internship is a frightening time for all of us. We’ve studied medicine for 4 years, memorized ungodly amounts of largely irrelevant material, played “doctor” in third and fourth year clerkships, but never before have lives actually been put in our hands. We know the expression, “never get sick in July” because that’s when all the well-intentioned, but generally incompetent new interns start caring for patients. And so, we tremble as we begin the new stage in our careers – applying our medical knowledge to real life situations, and praying that we don’t kill anybody.
I’ll never forget my first day of internship. I must have drawn the short straw, because not only was I assigned to the busiest, sickest ward in my hospital (the HIV and infectious disease unit), but I was on call that day (so I’d be working for 24 hours straight) with the most hated resident in the program (he had a reputation for treating interns poorly and being arrogant to the nurses). As I reviewed my patient list, I noticed that the sign out sheet (the paper “baton” of information handed to you by the last intern who cared for the patients – meant to give you a synopsis of what they needed) was supremely unhelpful. Chicken scratch with diagnoses and little check boxes of “to do’s” for me. I was really nervous.
So I began to round on my patients – introducing myself to each of them, letting them know that I was their new doctor. I figured that even if I couldn’t completely understand the sign out notes, at least by eye-balling them I’d have an idea of whether or not they were in imminent danger of coding or some other awful thing that I figured they’d be trying to do.
My third patient (of 15) was a thin, elderly Hispanic man, Mr. Santos. He smiled at me when I came
in the door – the kind of lecherous smile that a certain type of man gives to all women of child bearing age. I ignored it and introduced myself in a professional manner and began to check his vital signs. I was listening to his heart, and I honestly couldn’t hear much of anything. There was a weird, very distant beat – something I wouldn’t expect for such a thin chest. The man himself looked awful, but I really wasn’t sure why – he just seemed really, really ill.
My pager was going off mercilessly all night. I wondered if this was how the nurses got to know the characters of their new interns – to test them by paging them for anything under the sun, tempting us to tip our hand if we had tendencies to be impatient or disrespectful. But in the midst of all the “we need you to sign this Tylenol order” pages, there came a concerning one: “Hey, Mr. Santos doesn’t look good. Better get up here.”
My heart raced as I rushed to his bedside. Yup, he sure didn’t look too good. He was breathing heavily, and had some kind of fearful expression on his face. I didn’t really know what to do, so I decided to call the resident in charge (much as I was loathe to do so, since I knew he would humiliate me for bothering
him).
The resident appeared in a froth – “Why are you paging me? What’s wrong with the patient? Why do you need me here? This better be good!”
“Um… Mr. Santos doesn’t look too good.” I said, frightened to death.
“What do you mean ‘he doesn’t look too good?’ Can you be a little bit more specific” he said, sarcasm dripping from his tongue.
“Well, I can’t hear his heart and he’s breathing hard.”
“I see,” said the resident, rolling his eyes. He marched off towards the patient’s room, certain to make an example of me and this case.
I trotted along behind him, hoping I hadn’t been wrong in paging him – trying to remember the ACLS
protocol from 2 weeks prior.
The resident drew back the curtain around the man’s bed with one grand sweep of the arm. “Mr. Santos,
how are you doing?” he shouted, as if the man were deaf.
The man was staring at the wall, taking in deep, labored breaths of air. I saw that the resident immediately realized that this was serious, and he placed his stethoscope on the man’s chest.
I approached on the other side of the bed and held his hand. “Mr. Santos, I’m back, remember me?” He smiled and looked me straight in the eye.
He replied, “Angel.” (in Spanish) Then he let out a deep breath and all was silent.
The resident shook the man, “Mr. Santos? Mr. Santos?!” There was no response.
“Should I call a code?” I asked sheepishly.
“Nope, he’s DNR,” said the resident.
I was flabbergasted.
“Yep, you just killed your first patient. Welcome to intern year.”
As I thought about his cruel accusation, I was comforted by the fact that at least, as Mr. Santos released his final breath, he thought he had seen an angel. Maybe my presence with him that night did something good… even though I was only a lowly intern.
August 26th, 2009 by DrRob in Better Health Network, Opinion
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Something touched a nerve yesterday. I kind of lost my composure when someone tried to defend the insurance industry and responded out of emotion – perhaps putting aside some reason in the process.
I used to get mad at myself or embarrassed when this happened, but now I stand back and try to analyze my reaction. What is it that touched a nerve in me? Why did I feel so strongly? We don’t feel things without reason, and my reaction doesn’t necessarily betray weakness on my part, it shows the depths of my emotion. That passion usually comes from something – most of the time it is personal experience; and my personal experience says that insurance companies are causing my patients harm. That makes me angry.
I don’t think the people in the insurance industry are bad people. I think vilifying people is the easy way out. The people there feel like they are doing the right thing, and are no less moral than me. But I do not think the way to fix our system is through letting them do their business as usual in the name of “free market.” Defending the current system of insurance ignores some obvious problems in our system:
1. They are financially motivated to withhold services
If you hire a contractor to work on your house, how wise is it to pay them 100% in advance? You have just given them financial incentive to do as little work as possible, as it will maximize their profits to do so. The insurance industry is in such a situation; despite any good intention, they are put in a position to decide between profits and level of service. It is much better to pay more for better service, not worse; but that is what we have done with health insurance companies.
2. They have been given the ability to withhold services
If all United Health Care (for example) did was to provide insurance, they would not be vilified as they are. But since the only data available for medical care was the claims data they hold, they were put in a position to control cost. This was sensible initially, as they had both the data and the means (denying unnecessary care) of cutting cost. It’s OK that women aren’t kept in the hospital for a week after having a baby. It’s OK that I can’t prescribe expensive brand-name drugs when there is a reasonable generic alternative. There was a whole lot of fat to cut, and they did a good job cutting that fat.
The problem came when all the fat was gone and they were used to big profit-margins. Once there was not any more unnecessary care to cut, they had two ways to keep their profit-margins: increasing premiums or cutting services. They did both. Both of these have hurt my patients.
- Patients have had premiums increased or have been dropped because they were diagnosed with medical problems. I have had patients beg me “don’t put that in my record,” as they know a diagnosis of diabetes or heart disease will be disastrous. I am then caught between the pleas of my patients and the demands of honestly practicing and documenting my care.
- I do what I can to follow evidence-based standards, but there are times when people fall out of the norms. Medicine is not science, it is applied science. This means that I am trying to take an individual and somehow match them with the scientific data. Sometimes it works, but everyone is different. If something is true 90% of the time, 10% of the people will be exceptions to the rule. I have repeatedly been told by “gnomes” (people with minimal medical education who sit in front of a computer screen with a protocol for care) what “good medicine” looks like. They see things as black and white when it is just not that way. This has caused people to be unnecessarily hospitalized, it has required them to get unnecessary tests to follow their rules. There is no arguing with people in front of computers.
3. They covertly ration
Dr. Rich Fogoros (whom I recently met) has coined this phrase to explain what happens in our system. Because it doesn’t look good to deny necessary care, insurance companies (including government-run ones) resort to making things exceedingly complex. This makes it look like care is being offered, but not taken advantage of. What does this mean?
- The burden of proof is put on the provider to show the tests ordered are necessary. The assumption is that a test will be denied unless the doc can prove otherwise.
- Tests are sometimes inappropriately denied. They then can be appealed, but the appeal process is even more difficult than the initial approval process, and so some people give up. Every time someone gives up, less is paid out by the insurance company and their profits go up.
- The rules for coding and billing are so complex, that it is very easy to make mistakes. This means that an appropriate test ordered by a doctor that is not perfectly coded doesn’t get paid for. The patient gets the bill and must get the doctor to appeal the denial. This appeal process, again, is difficult.
Because of this, I have to hire staff whose sole task is to learn all of the rules of the different insurance carriers (including public ones) and then play the game properly with them so that we get as few denials as possible. I probably spend $70-80 thousand per year to deal with the frustratingly complex system we have.
————
I have health insurance. I do understand why it needs to exist, but I also see how harmful the current state can be to my patients. I get frustrated with Medicare and Medicaid as well, but that is not my point. Just because government run insurance has problems doesn’t do anything to change the problems with private insurance. The fact that you can be killed by firing squad doesn’t make the gallows any better.
The cost of care has gone up dramatically over the past 10 years while my reimbursement has dropped. Where is that extra money?
But the system is very broken right now. It needs to be fixed. Things need to be changed in both the private and public sector. When I was in DC I made the point that our ship is sinking and we are arguing about who will be the captain. The problems in our system are not simply who is writing the checks.
Honestly, I don’t really care who writes the checks. All I want is for the system to reward good care and to stop hurting my patients. Those who deny the reality of either of these problems will invariably draw my ire.
*This blog post was originally published at Musings of a Distractible Mind*
August 24th, 2009 by Toni Brayer, M.D. in Better Health Network
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Ever wonder what the doctor is looking for when she shines the light into your eyes, up close and personal?
This is what she sees if the patient has severe hypertension. The retina shows blurring of the optic disc (in the middle left) and the white areas are called “cotton wool spots”. The blurry part at the bottom is a partial retinal detachment. The patient’s blood pressure was 220/150.
*This blog post was originally published at EverythingHealth*
August 21st, 2009 by CodeBlog in Better Health Network, True Stories
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Just over a month ago, our unit had several H1N1 flu patients. And they were sick. Really really sick. They were also fairly young – 30’s to 50’s. I wondered at the time why the media hullabaloo about the flu had died down when I was seeing more and more patients in my unit who had it.
Last time I worked there was only 1 flu patient and they weren’t too sick (yet?) to require a ventilator. I was really glad to see the decrease in this particular patient population. I won’t lie – it’s frightening to be a nurse caring for someone with a highly communicable disease. Masks, gloves, gowns are all provided by the hospital, but I can’t ever shake the feeling that I’ve somehow come in contact with it despite these precautions.
And what of the times that we admit patients and don’t know they have a communicable disease? At least one coworker I know of contracted H1N1 from taking care of a patient who had it before we knew they had it.
I’m sure she was quite shook up – every single patient who turned up positive for the flu in our unit in that time period ended up literally fighting for their lives on a ventilator.
The most harrowing patient we had was a woman in her 30’s who was pregnant. Like the other patients, every time she coughed on the vent, her oxygen saturations would decrease to the 80’s and would take a long time to come back up. Unlike the others, though, she was so fragile that sometimes merely coughing on the vent caused her to go into asystole.
I’m somewhat jaded about coding people at this stage in my career. I remember, as a brand new ICU nurse, talking to a well-seasoned ICU nurse. She said that hearing “code blue” being announced overhead didn’t give her any kind of adrenalin rush anymore. At that time, I couldn’t imagine being in that frame of mind. Being new, I was expected to go to every code blue that was called so as to get experience. My heart started going into SVT at simply hearing the word “code.” If the word “blue” came after I practically had to defib myself before running off to defibrillate the patient.
I eventually got to a place where I could fairly confidently go run a code without freaking out. I’ve been an ICU RN for 11 years. In those 11 years, there have been some awful codes. Two stand out in my mind, and the absolute worst was on the pediatric floor. When I heard “code blue, pediatrics” overhead, my first (naive) thought was, “little kids code???” My second thought was to wonder if it was really an adult overflow patient. Sometimes the gyn surgeries went to the pediatric floor if there was no more room on the surgical floors. You know, maybe one of them got a little too much morphine and the nurse called a code. A little Narcan, a few bagged breaths and everyone would sigh with relief and go on with their day.
No such luck. After running full speed up 3 flights of stairs, I arrived at the room that had the most people spilling out of it only to find a bald, thin 5 year old in the bed. I thought I was going to be sick. PICU nurses – bless you all. I could not do that for any length of time.
She didn’t make it. Having been a nurse for a couple of years at that point, my naivety about the world already had a few chips and cracks in it. But on that day a huge chunk fell out.
Since then I’ve come to be more like that seasoned ICU nurse that I spoke with so early in my career. Along with the semi-jaded “oh crap, a code blue” comes a confidence in one’s abilities, so it’s not all bad.
However, watching that woman go into asystole, knowing that we would have to crash c-section her if she stayed in it? That took me back to the days when I was new and inexperienced. I’ve never seen anything like that happen. Although I was perfectly comfortable with my (pre-arranged) personal role, the overall situation would be completely new to me.
Although HIPAA prevents me from saying much more, I will say that I did not have to experience that situation; not because I was off when it happened but simply because it never happened.
If it had, it surely would have made my top 3.
*This blog post was originally published at code blog - tales of a nurse*
August 20th, 2009 by BarbaraFicarraRN in Better Health Network, Health Tips
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A Guest Blog by Kevin Soden, MD
I ran into an old friend this past week and, as all of us over 60 do, we began talking about our health and the various ailments afflicting us as we age.
He shared with me that he was currently dealing with a bad case of the “shingles” (known as Herpes Zoster in medical circles) at age 65 and how terribly painful they were. He said that he wouldn’t wish them on his worst enemy.
As many of you may know because you’ve suffered a similar problem, shingles is caused by the Varicella Zoster virus, the same virus that causes chickenpox.
Only someone who has had a case of chickenpox – or gotten chickenpox vaccine – can get shingles. The virus stays in your body and it can reappear many years later to cause a case of shingles.
Always being the doctor, I asked my friend whether or not he’d gotten the vaccine to help reduce his risk of getting shingles.
He acted shocked and was quite angry as he explained that he’d never been told by his doctor about that there was a vaccine available that might prevent shingles.
The vaccine available for adults 60 and over to prevent shingles is called Zostavax. In clinical trials, the vaccine prevented shingles in about half of people 60 years of age and older. Even if you do get shingles after being vaccinated, it may help reduce the pain associated with shingles but it cannot be used to treat shingles once you have it.
I’m really not pushing the Zostavax vaccine because it’s not recommended for everyone but rather am reminding everyone that prevention is much better than treating after someone has a disease.
Talk to your doctor at your yearly visit to see what preventive steps you should be taking.
Check the CDC website for more information about vaccines that might be right for you especially if you are traveling to other countries.
Frankly, if your doctor is not talking to you about preventing disease, then it just might be time to find another doctor.
About Kevin Soden, MD
Dr. Kevin Soden has been a medical journalist for over 20 years appearing on CBS, NBC and most recently on NBC’s Today Show. He now serves as the host for Healthline, the national award-winning daily medical television show seen on the Retirement Living Network. He also serves as the worldwide Medical Director for Texas Instruments and Cardinal Health and teaches as a courtesy Professor at the Univ. of Florida College of Medicine.
His awards include 3 Telly’s, the 2008 CableFax award for best cable health show, the 2008 and 2001 National Award for Excellence in Medical Reporting from the National Association of Medical Communicators, a finalist for the International Freddie Awards in 2001, and as the Executive Producer for Rush of the Palms received the 2003 International Film Critics award for short films.
Kevin published The Art of Medicine: What Every Doctor and Patient Should Know…a critically acclaimed book focusing on improving doctor-patient communications. He is also the primary author of a consumer medical book Special Treatment: How to Get the High-Quality Care Your Doctor Gets. He is also a contributing author to the recently published A Practical Approach to Occupational and Environmental Medicine and to Physician Leaders: Who, How and Why Now? He has just finished his third book Think Like a Man: Male Behaviors that Can Help Woman Lighten the Load, Loosen Up and Find Happiness in a Stress-Filled World. He also is a regular contributor to numerous popular magazines.
Soden graduated with honors from the University of Florida College of Medicine and is one of the original inductees into the UF Medical Wall of Fame. He also has a Masters in Public Health from the Medical College of Wisconsin and a Masters in Personnel Administration from Florida State University.
*This blog post was originally published at Health in 30*
