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Baking cookies, Part 2

One day I was consulted on a patient in the surgical
ICU. It is uncommon for rehab physicians
to be called to the SICU, and so en route, I pondered what I might find. Maybe a multiple trauma patient who needs a
walker or chest PT?

As it happened, the patient was a 21 year old male who had
gotten into a fight in the West Village. He was hit on the head with a blunt object, resulting
in a subdural hematoma and severe brain injury.
He was intubated, sedated, and expressing decerebrate posturing (a
really bad sign).

The surgeons had called me because they were concerned about
pressure ulcers and contractures. They
wanted to initiate physical therapy and stretching exercises to make sure that
his Achilles tendons didn’t shorten irreparably as his feet were pointing
downward in the bed. Although I thought
it was great that the surgeons were planning ahead like that, truthfully I didn’t
think the patient would ever walk again, or perhaps even survive the SICU. The level of brain injury was just too
severe.

I wrote orders for daily physical therapy, got him some Multi Podus Boots, and recommended frequent turns in bed.
I figured I’d never see him again as I was scheduled to change rotations
and transfer follow up of this consult to another resident. It was a tragic case.

About 2 months later I began an inpatient rotation and was
listening to the story of several patients whose care was being transferred to
me. As the resident presented the final
one, I thought the story sounded familiar.
A young man out partying with his friends, got into a fight, sustained a
severe brain injury after being hit in the head…

“This isn’t the guy I saw in the SICU 2 months ago, is it?” I asked the resident.

“Yeah, that’s the one!
I remember seeing your note in the chart. The PTs did a great job with his ankles – he could
stand on them just fine when he got up.”

“Dude, no way! When I
saw him he was posturing in the SICU… this guy actually recovered?!”

“Yeah, I know… he’s the first one I’ve ever seen like this. Do you wanna see him?”

“Heck yeah,” I said, “I’ve got to see this with my own eyes.”

My colleague led me down the hallway to the occupational
therapy kitchen. As we got closer, a
wonderful chocolatey smell filled the air.

“What smells so good?” I asked.

“Oh, the patient is making cookies with the occupational
therapists. He’s learning how to cook
and take care of himself.”

I rounded the corner into the kitchen and there was a young
man, handsome and healthy, pulling a tray of cookies from an oven – I could barely believe it was the same
person.

“Hey doc,” he said to me – not recognizing me of course, but
friendly nonetheless. “You want a
cookie?”

“I’d love a cookie,” I said, remembering the last time I had baked them.

“I believe that this is the best cookie I’ve ever tasted,” I
said, looking at the man with tears in my eyes.

He grinned from ear to ear.

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

The case of a predator in the hospital

Several years ago I was taking care of a pleasant elderly woman with a heart condition on an inpatient unit. One morning I went into her room to check on her and I found her sitting up in bed, clutching her purse and crying.

“What’s wrong, Mrs. Johnson?” I asked, perplexed.

She blew her nose in a Kleenex and replied, “Someone stole my insurance cards, my money, and my credit cards! They were in my wallet just yesterday evening – and this morning they’re gone.”

I paused for a moment, considering the order of priority in which she reported the missing items, glanced at her telemetry monitor (her rhythm was regular though her heart rate was elevated from crying), and asked if she knew how this might have happened.

She told me that she suspected that a certain patient had sneaked into her room in the middle of the night and removed the items from her wallet.

“How do you know it was that patient?” I asked, growing suspicious.

“I’ve seen her sneaking around at night in other people’s rooms – a couple of nights ago she was in here digging through my roommate’s dresser drawers.”

The suspect was a 38 year old woman with a known history of heroine abuse, who was admitted to the General Surgery service (conveniently boarded on our Internal Medicine floor) from the Emergency Department to complete an acute abdominal pain work up. This woman had already terrorized the surgical intern assigned to her case (as I had heard on rounds the day before) by chasing her around the hospital room with a hypodermic needle. Security had come to restore order and had found a stash of heroine and some needles in her bathroom that had been brought in by her visitors the night before. The team decided not to discharge her because they had discovered a large abscess on her ovary (from an advanced and untreated sexually transmitted disease) that they felt obligated to drain and treat her with antibiotics. Of course, on the morning of her scheduled surgery she ate breakfast, making it unsafe to put her under general anesthesia. These games continued (sneaking food before surgery, refusing surgery or medications, then changing her mind, then claiming to be homeless with no safe discharge plan, etc.) so that her length of stay grew from days to weeks.

“And now,” I thought to myself, “she’s using our hospital as a flop house, victimizing MY patients on the same floor – stealing their belongings in the middle of the night?!” This was the last straw. I told Mrs. Johnson that I would get to the bottom of the matter.

And so I waited for the victimizer to leave her hospital room for a scheduled test – I sneaked into her room and went through her bedside table drawers. Lo and behold, my patient’s ID and credit cards were stashed in a box with a bunch of other IDs that clearly didn’t belong to the woman.

I called hospital security, and we reviewed all the items that she had stolen. As it turned out, she was admitted to the hospital under a stolen Medicare card (the woman had claimed to be on disability). Her name matched with our records of a 67 year old woman, so we knew that she had been admitted under another’s name – and the admitting clerk had not noticed the age discrepancy. A careful record search turned up the drug user’s previous admissions under this alias. This predator had been gaming the system for years, eluding detection!

I asked the security guards to help me interview other patients on the inpatient unit to see if they had experienced anything out of the ordinary over the past few weeks. What we found was astounding. Several frail elderly patients described similar night terrors (being unable to stop the woman from going through their personal items at night) and one gentleman with advanced AIDS, who was admitted for treatment of severe pneumonia, reported that the woman had attempted to molest him in the middle of the night when she was high and in a hypersexual state.

Thanks to our investigation, many patients had their belongings returned to them (though some of their jewelry was not recovered – the woman probably sold it for heroine to her visiting dealer), and I heard that the predator was caught by the city police after choosing to leave the hospital against medical advice.

I don’t know what happened to this woman after that, and I doubt that the police were able to detain her for very long. I felt horrible for the patients who had been victimized in their ill and vulnerable states, and I wondered what kind of lasting psychological damage that this woman had inflicted upon them, especially poor Mrs. Johnson. I also felt frustrated and vulnerable – unable to really protect my hospital from future assaults. What could I do, stand in the Emergency Department each night to identify her if she chose to return? I can only imagine that this woman is still up to her old tricks at a neighboring inner city hospital near you…

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

Young and uninsured in Manhattan

My friend forwarded an article to me from New York Magazine. It is about the fact that many of the “20-somethings” in Manhattan choose not to buy health insurance. They reason that nothing really bad is likely to happen to them, so why pay the $167-300/month in health insurance?

Here are some of the strategies that these young uninsured use to stay out of harm’s way:

  • “I carry an expired Blue Cross card in my wallet. You never know, maybe they’ll think I have insurance and I’ll get better care.”
  • Rebekah takes vitamin C and echinacea.
  • “I do yoga to stay loose. I drink a lot of water so I don’t get sick, and vitamins.”

Ironically, Echinacea is actually a cousin of rag weed, and can create a cross-reactivity that may cause cold-like symptoms (leading the user to believe that she averted a more severe cold by taking the supplement). Vitamins are unregulated, and previous studies have shown that up to 50% of bottles do not contain the actual levels of vitamins and minerals displayed on their labels. Dangerously high lead levels have been found in popular multi-vitamins as well. Of course, there was a recent bottled water scare – with a certain brand found to contain high levels of arsenic. Yoga can be harmful to those who push themselves too hard, and to my knowledge there is no convincing evidence that high levels of vitamin C can retard viral illnesses.

Why don’t the young adults buy health insurance? Here’s what one young man said:

“What’s ironic is that I would never live without my cell phone, but I won’t consider buying health insurance. It sounds ridiculous to say that out loud, but the fact is insurance is just too expensive. If it was the same price as my phone”—$150 a month sounded reasonable to him—“I’d buy it in a second.”

The article goes on to describe a nightmare case of an uninsured young man who developed appendicitis. He ended up requiring surgery, and a prolonged hospital stay due to infection. His total bill was $37,000.00. He explained to the hospital that he couldn’t afford to pay, he discovered that he made too much money to qualify for Medicaid, so he sent them a nasty letter, threatening to sue them for malpractice. The hospital reduced the charges to $1,700.00.

A year later when asked if he now carried insurance, here is what the man said:

“Oh, no, I still don’t have any insurance,” he said, rolling his eyes to indicate that, yes, he knows how it sounds. “I think about it, but it’s not like I have a consistent income right now. I think about paying $300 a month on top of my other expenses, and it’s like, God, when’s it going to end?” He paused. “But, really, it’s more than that. I was just so disillusioned with the process. I wanted nothing to do with it, you know? And maybe because, in the end, I kind of managed to get away with it, I end up thinking …” He trailed off, not finishing the thought, but the sentiment was clear: He is still young, he runs, he does yoga, he takes all the vitamins. And it’s not like you can get appendicitis twice.

***

New York hospitals alone provide $1.8 billion in uncompensated care annually.

***

Are you sympathetic to the uninsured’s plight, or do you feel annoyed by their attitude?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Hope for accident prone kids

My mother had a good deal of trouble with me, but I think she enjoyed it.

–Mark Twain

Parenting is a difficult job – and one that few would sign up for given full advanced disclosure. I suppose my parents had their share of woes – my near-death experience as an infant, my being mauled by a vicious dog as a toddler, my getting lost in the woods (collecting poisonous toad stools) at age 4, my facial surgery after a bicycle accident, my head injury from a fall out of the tree house, my toboggan versus barbed wire fence encounter, my front teeth versus metal bar incident, my rib fractures and nearly ruptured spleen from another fall from a bunk bed, and my ski accident requiring knee reconstruction surgery… I guess you could call me accident prone.

Looking back it makes sense why my parents encouraged me not to play contact sports, but pursue academics. I took to jogging and tennis instead (yes, I managed to sprain my ankle and catch a racket to the eye nonetheless), and physical training in the gym. But my redirection towards reading and homework was probably a good thing – as it helped me to develop intellectual discipline, and at the very least kept me out of the ER.

So what is the moral of this story? I guess if you have a kid who’s physically challenged – or at least seems to be a magnet for high velocity metal objects, do not lose heart. With a little direction, he or she can grow up to become a doctor who helps other kids who injure themselves repeatedly in creative and unexpected ways.

Were you an accident prone kid, or do you have an accident prone kid? I’d like to hear some of your war stories!

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

Are physician salaries too high?

I am opposed to millionaires, but it would be dangerous to offer me the position.

–Mark Twain

As we consider the wastefulness of the healthcare system, I have heard many people complain that physician salaries are one of the main culprits in escalating costs.

Dr. Reece compares the average income of some of the highest paid physician specialists, with that of hospital executives, medical insurance executives, and fortune 500 CEOs. Check this out:

Highest Paid Physicians

1. Orthopedic, spinal surgery, $554,000
2. Neurosurgery, $476,000
3. Heart surgeons, $470,000
4. Diagnostic radiology, Interventional, $424,000
5. Sports Medicine, surgery, $417,000
6. Orthopedic Surgery, $400,000
7. Radiology, non-interventional, $400,000
8. Cardiology, $363,000
9. Vascular surgery, $354,000
10. Urology, $349,000

Executive Pay for Massachusetts Hospital CEOs

1. James Mongan, MD, Partners Healthcare, $2.1 million
2. Elaine Ullian, Boston Medical Center, $1.4 million
3. John O’Brien, UMass Memorial Medical Center, $1.3 million
4. David Barrett, MD, Lahey Clinic, $1.3 million
5. Mark Tolosky, Baystate Health, $1.2 million
6. James Mandell, MD, Children’s Hospital, Boston, $1.1 million
7. Gary Gottlieb, Brigham and Women’s Hospital, $1 million
8. Peter Slavind, MD, Massachusetts General Hospital, $1 million

2005 Total Annual Compensation for Publicly Traded Managed Care CEOs

1. United Health Care $8.3 million
2. Wellpoint, Inc, $5.2 million
3. CIGNA, $4.7 million
4. Sierra Health, $3.4 million
5. Aetna, Inc, $3.3 million
6. Assurant, Inc, $2.3 million
7. Humana, $1.9 million
8. Health Net, $1.7 million

Top Corporate CEO Compensation

1. Capital One Financial, $249 million
2. Yahoo, $231 million
3. Cedant, $140 million
4. KB Home, $135 million
5. Lehman Brothers Holdings, $123 million
6. Occidental Petroleum,, $81 million
7. Oracle, $75 million
8. Symantec, $72 million
9. Caremark Rx, $70 million
10. Countrywide Financial, $69 million

But the real story here is the salary of our primary care physicians – those unsung heroes of the front lines. KevinMD pointed out a recent news article citing $75,000.00/year as the average salary of the family physician in the state of Connecticut, and that their malpractice insurance consumed $15,000.00 of that. Although this is certainly below the national average for pediatricians (they start at about 110,000 to 120,000), I’ve seen many academic positions in the $90,000 to 100,000 range.

Now I ask you, does it seem fair that the vast majority of physicians (the primary care physicians) are making one tenth of the average hospital executive salary? Should doctors really be in the cross hairs of cost containment?

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

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