Dr. Wes

Code Blue, Then and Now

2009-11-22T09:20:00.003-06:00

Then:

11:30 pm - Cackling though the overhead intercom system:
“Code Blue, Three East, Room 236”

A thunderous herd of medical students, residents, anesthesiologists, cardiologists, social workers, security personnel descend on the scene. Arriving, the chief resident is in charge at the foot of the bed. IV’s have been started, some young well-muscled individual is bobbing up and down on the unseen’s chest, brow glistening with sweat, but focused. An anesthesiologist, noting the agonal rhythm, works to secure the airway, then a central line. Nurses administer drugs, bring line kits. Airway secured. “EKG? Where’s the EKG?” Electrode replaced. “Story? Who’s got the story?” Ten. Twenty. Thirty. The minutes pass. Finally, silence, as the monitors removed and the group departs. Like sound and fury, signifying nothing.

Now:

11:30 pm – The pager sounds:
* bleep bleep bleep *
A digital image appears on the screen: CODE BLUE, Room 2001

I was not on call, but I wondered, “Was this a patient of mine?” “Did I forget someone?” I raised my head from the pillow and strolled in to the accompanying room where my outdated computer sat and waited while it booted. “What might have happened?” “Is it someone old or young?” Thoughts spun just as the disk drive. Waiting. I typed by keyfob’s codes, I entered by password twice, I waited some more then the electronic medical record appeared and I checked the name next to the room number. For the first time, the number meant something: a person, 88 yrs old, yet someone I did not know. The scene appeared from miles away.

I sat back and perused the chart. Heart attack, conservative management, hypotension, fluid bolus given, then nothing more.

A few more keystrokes and the computer went black.

Then sleep came poorly once again.

-Wes

What To Opt Out of Medicare?

2009-11-21T22:28:00.004-06:00

Here's how, courtesy of Mayo Clinic Family Medicine - Arrowhead (Arizona):

The discrepancy between what Medicare pays and our cost of providing care acutely impacts the sustainability of our primary care practice. Medicare reimbursements do not cover our actual costs of providing care, and therefore we have recently had to make some difficult decisions that will impact the Arrowhead Family Medicine practice. Effective January 1, 2010, the physicians at Mayo Clinic Family Medicine - Arrowhead will opt out of participating in Medicare, meaning that Medicare will no longer reimburse for the services they provide....

With the $500 billion dollars of cuts to Medicare spending in the new health care bills proposed, will we see more of this in more affluent areas?

-Wes

Early Health Care Reform Photoshop Entries Are Up

2009-11-20T13:43:00.009-06:00

Early US Health Care Reform Photoshop Contest entries are available to view here. (I did the one at left - sorry, it's ineligible). There's still plenty of time to submit your entry. Entries will be still be accepted until 30 Nov 2009 at 23:59 pm CST!

-Wes

As Hospitals Gain Cardiologist Employees, Private Cardiologists Are Shunned

2009-11-18T09:20:00.005-06:00

An interesting story has developed in Missouri where a private group of cardiologists was asked to no longer see their patients at the local hospital. It seems the hospital hired it's own group of cardiologist-employees. Things grew so contentious according to the video accompanying the report, when the cardiologists asked for an OR lite, they were told to use a flashlight (the hospital disputes the claim).

As the cardiologist shift to adjust for the economic realities that confront them, they have much more to lose from their patient relationships as its the patients that are inevitably affected the most when these shifts occur.

-Wes

Sebelius: Talking the Talk or Walking the Walk?

2009-11-17T14:38:00.010-06:00

Here's a bit of the transcript from Kathleen Sebelius, Department of Health and Human Services Secretary, speaking to the Wall Street Journal's CEO Council (approximately 2 min, 45 sec into video) about saving health care costs:

... There are lots of features of the House Bill and that are already in the Senate bill that change that (the way doctors are paid). We are beginning to move away, particularly in Medicare, from traditional fee-for-service pay that I would suggest not only causes redundancy but doesn’t encourage innovative, high quality, low cost practices to moving toward a system that exists in pockets, exists in Mayos, Geisinger, (Inter-)Mountain Health Care. We know what it looks like. It isn’t how medicine is practiced it isn’t the the hospitals and providers are paid, so "bundled payments," "medical care homes," "accountable care organizations" – all buzzwords for really providing financial incentives and eventually financial penalties for appropriate medical protocols and appropriate outcomes - stopping the system now where one out of every five who’s released from the hospital is back in 30 days having never seen a health care provider, reducing or eliminating hospital-based infections, which are now one of the top 10 leading causes of death in America. We know exactly the system that can be done to stop it. It doesn’t take any capital investment It doesn’t require any new technology.”

I wonder what she means by "... eventually financial penalties for appropriate medical protocols and appropriate outcomes?"

Why penalize people for adhering to appropriate medical protocols? Or maybe she just needs some sleep...

And then there's this quick fact check:

Septicemia: #10 in 2006 (1.3% of deaths) CDC list for death in America and was #11 in 2004 (1.4%) but is substantially better than rates in 1997 (2.4% of deaths).

(Just keeping it real.)

-Wes

Medical Bloggers' Grand Rounds Is Up

2009-11-17T11:49:00.003-06:00

... this week over at Colorado Health Insurance Insider.

-Wes

Compensating Doctors for After-Hours Call Coverage

2009-11-17T05:13:00.008-06:00

Should there be a premium added to physician compensation for on-call coverage after hours, or are Medicare rates enough?

This appears to be the central question between two competing hospitals in Longview, Texas where a $300,000 stipend was paid to a cardiology group by one hospital and not the other for cardiology on-call coverage.

Guess which one the doctors are promoting now?

Banos said the Diagnostic Clinic cardiologists recently approached Good Shepherd "demanding hundreds of thousands of dollars in compensation from Good Shepherd for providing call coverage to the patients of Good Shepherd."

"This is in addition to whatever money they are able to bill and collect from patients and their insurance companies for the services they actually provide when they are called in to perform a procedure," Banos said in his e-mail to Good Shepherd employees.

Banos said he believes the demands for compensation were "veiled threats to move their elective procedures to Longview Regional if we did not pay." He added Good Shepherd's stand is that meeting the compensation demands would "not be fair to the many other physicians on our medical staff who selflessly and without any expectation of pay [from the hospital] provide call coverage to our patients each day as part of their commitment to the community."

"We cannot meet the needs of our community and pay doctors for doing something that they are already obligated to do as a part of their community obligation" Banos said.

Banos said he believes Longview Regional agreed to pay the cardiologists more than $300,000 a year for on-call coverage.

"We do not believe that it was by chance that it was only after this agreement was reached that these physicians touted Regional's 'commitment to quality care' and announced their 'choice' of Longview Regional for their patients." Banos said. "We knew that taking a stand could result in these physicians moving their elective cases to Longview Regional, and it did."

Before condoning the cardiology groups' actions strictly on the basis of greed, we should note that there is a precedent for higher pay for employees working after hours in industry. Hospitals, too, have resorted to paying "nocturnists" (night-shift hospitalists) higher salaries than their daytime hospitalist counterparts as they struggle to find staff willing to work the night shift managing inpatients. These salaries are not covered strictly by funds received from the paltry Evaluation and Management payments paid by Medicare, rather, they are subsidized by the hospital system.

Threatened with unprecedented pay cuts from Medicare, look for this trend to continue as doctors use their only remaining asset, patient referral clout, to negotiate their compensation going forward.

-Wes

How Not to Consent a Patient for Angioplasty

2009-11-16T09:22:00.004-06:00

Yikes!

"Honey, all you need to worry about is if I am going to listen to opera or Steely Dan during the procedure."

-Wes

P.S. I told you "Honey" was bad.

US Health Care Reform Photoshop Entries

2009-11-15T06:14:00.017-06:00

Last updated 19 NOV 2009 @ 08:00 AM.

Early entries for the US Health Care Reform Photoshop Contest are shown below in the order they were received. Remember, the deadline for entries is 11:59 CST 30 Nov 2009. This post will be updated from time to time as new entries arrive.

(Editor's note: We're putting the entries up as they're sent. Remember, you'll ultimately be the judge.)

1) "Health Care Cat" (in the spirit of LOLCats):

2) "Gonnorrhea for Rationed Health Care"

3) "Healthcare Budget":

US Health Care Reform Photoshop Contest

2009-11-15T00:01:00.005-06:00

In the spirit of the upcoming holiday season and to make sure something on health care reform gets done before the end of the year, Dr. Wes and his wife, Diane, would like to propose the first (and perhaps only) US Healthcare Reform Photoshop Contest.

Bring us your snark, your wit, your creativity about the health care reform efforts encapsulated in a single photograph. Photographs in support or against the current efforts will be equally considered, and you, dear internet devotees, will be the final judge. The winner receives an iPod Touch.

Rules: No more than one photo entry per household, please. Create a single photo using Photoshop or other equivalent photo-editing software that encapsulates the essence of health care reform as you see it. Photographs must be G, PG, or PG-13 rated and family-friendly (R or X-rated photographs will be enjoyed, but not eligible or posted). An example image we created is shown above. Please do NOT use copyrighted photos.

E-mail your entries to me at wes - at - medtees dot com (please keep file sizes under 100K) with your name, address and e-mail contact information and I'll post the vetted entries on a webpage on this blog in the order they are received. If the response is overwhelming, we reserve the right to limiting the images posted to our discretion.

Depending on the number of entries, our highly distinguished referees (my wife and I) will choose the five or six photographs that will serve as the finalists by no later than 11:59 PM on 30 November 2009. On 2 December 2009 or so, the chosen finalists will be displayed and the polls will open for you to choose the winner. The photograph with the most votes tallied will receive an 8Meg iPod Touch. Voting on the finalists will close 11 Dec 2009 at 11:59 PM. This way, we hope there's plenty of time for our prize to reach the winner before the holidays and final health care reform vote. In the unusual event there is a tied vote, we will chose the winner between the two favorites.

So get going, be creative and most of all, have fun!

Happy holidays!

- Wes and Diane

P.S.: Please spread the word!

FTC Disclaimer: No advertising sponsors are supporting this contest.

Addendum:

If you'd like to help promote this contest on your blog by placing this tacky button on your sidebar, just copy the HTML in the textbox below and add it to the your blog's sidebar code:

Problems With Low-Energy External Defibrillators?

2009-11-13T09:31:00.005-06:00

Seems the FDA wants to know more:

FDA is investigating energy levels in (automatic) external biphasic defibrillators (AEDs) with shocks ≤ 200 J. FDA has received reports of 14 events since 2006 in which a 200 J biphasic defibrillator was ineffective in providing defibrillation/cardioversion therapy to a patient, whereas a subsequent shock from a different 360 J biphasic defibrillator resulted in immediate defibrillation/cardioversion. The majority of events occurred during attempts at cardioversion of atrial fibrillation, but there was at least one instance with defibrillation of a ventricular arrhythmia as well. FDA is seeking additional information in order to interpret the significance of these events, and to determine whether FDA activities are advised.

I haven't seen this, but others may have, so let 'em know.

-Wes

Waiting, and Hoping, For a Heart

2009-11-13T04:45:00.013-06:00

A patient, recently listed for cardiac transplantation, tells his story about being rejected, then accepted, to the cardiac transplantation list:

Next week, I'll check into Mayo, one of the world's premier hospitals, to undergo additional treatment in preparation for receiving a new heart. Since my brain tumor turned out to be benign and my prostate cancer has responded to treatment, doctors there said those issues no longer should disqualify me as a candidate for a heart transplant.

Now that I'm on the list, I am on an around-the-clock standby alert. I have to be ready to be on the operating table within four hours once a compatible heart becomes available. The fact that Chicago is 331 miles from Mayo, in Rochester, Minn., complicates things since I don't have my own charter jet. But the Mayo Med Air charter service could assist me if a commercial flight can't get me there quickly enough.

The challenge now is the wait. The heart I need will become available only when the donor is declared brain-dead and his heart can be taken from him and implanted in me within four hours. I am told the fact my blood type is B positive increases the chances of me getting a transplant quicker, though there are other patients ahead of me.

I had wanted it all to happen at the University of Chicago Medical Center, where world-renowned Dr. Valluvan Jeevanandam, who performed a triple-bypass on me in 2001, has done more than 1,000 transplants. But that hospital takes a more conservative approach to the fact my prostate cancer still is in remission. They wouldn't put me on the transplant list until I had been using an implanted heart pump ''for several years.''

Fortunately, the Mayo Clinic and Northwestern Memorial Hospital feel I have progressed enough in my recovery from the slow-growing prostate cancer to be eligible for a heart now.

With the competetion for patients underway as the large health care system land-grab extends across state lines and overseas (See here and here), have the selection criteria for transplant patients remained a form of rationing or really become a form of marketing?

I wonder.

-Wes

How to Find the Arrhythmia Patient's Room

2009-11-12T20:51:00.007-06:00

When it's 1:00 AM and you're not sure where the patient with incessant ventricular tachycardia is located in the ICU, just turn to the telemetry strips:

Click image to enlarge

-Wes

Need a New Medical School?

2009-11-12T20:18:00.004-06:00

... just be a holdout on the vote to approve the House health care bill:

In a statement, Costa said he succesfully negotiated funding for a UC Merced medical school.

"I am voting for HR 3962 because the choice of doing nothing was not an option. During my negotiations to help improve the bill for our Valley, I was able to achieve funding for a medical school in the Valley, with studies at UC Merced and residency in Fresno, as well as additional incentives to bring health professionals to our Valley. Increased funding in this bill for programs ranging from nurse training to health career opportunity programs to community health centers and increased reimbursement rates for low-paying Medicaid will go a long way in strengthening our health system in the Valley," Costa said.

The bill, HR 3962, passed the House of Representatives with a vote of 220-215.

Cardoza said the bill directs $167 million in health care funding to hospitals in his 18th district alone. The district includes parts of Fresno and Madera counties. But Cardoza said he still has concerns about the cost of the bill.

I love the last sentence: "... and he still has concerns about the cost of the bill."

Yeah, right. And if you believe that, I've got some oceanfront property in Arizona I'd like to sell you...

-Wes

Frontloading Surgical Performance

2009-11-12T14:51:00.006-06:00

I must say, in all the years I have been practicing medicine, I have never seen a "thank you" gift delivered before surgery, but recently, our team got delivered this:

Click image to enlarge

Needless to say, I was floored.

But then I read the note, which was priceless:

Click image to enlarge

Fortunately, all ended well, and no "oops" were had.

But talk about the pressure to perform well!

:)

-Wes

The House Health Care Bill and Bureaucratic Duplication

2009-11-11T11:00:00.007-06:00

I don't mind health reform. In fact, I believe we need it. But when reform bills fund projects that already exist, or fund special projects for other non-health care professionals, like lawyers, I have to wonder what Congress is doing.

The recently passed House bill (H.R. 3962 pdf) contains a multitude of grants and "demonstration projects." I wasn't sure what some of these grants were meant to support, so I looked them up. I was surprised to find that many of the grants duplicate programs or departments already in place. While this list is by no means comprehensive, I thought I would provide a few comments on a few of these grants shown in italics):

Grant program for "community-based collaborative care"
(Seems this is really a grant to fund telemedicine programs and HL-7 hospital coding standards so computers can talk together. While ultimately this should be a good thing, the grant actually has little to do with collaboration of health care in the community right now.)

Grant program to develop infant mortality programs
(Why is more money needed when a department already exists for this?)

Grant program for reducing the student-to-school nurse ratio in primary and secondary schools
(Forget teachers, stick with nurses for schools I guess)

Grant program so "No Child is Left Unimmunized Against Influenza"
(And yet, I'm sure we'll soon have a Pay for Performance measure for that)

Grant program to implement medication therapy management services
(Once again, never mind this has already been done)

Grant program for community-based overweight and obesity prevention
(been there, done that, but it seems we can never get enough of this.)

Sec 2221 (pg 1246) Grant program for nurse-managed health centers
(APN's doing "primary care." Can't help wonder why the AMA loves this bill. Where's there support of what we do?)

Grant program to support demonstration programs that design and implement regionalized emergency care systems
(already being done in certain communities. The natural question is how much money is anticipated for the multitude of communities in need.)

Grant programs to prepare secondary school students for careers in health professions
(What ever happened to "Career Day?")

Grant programs for community prevention and wellness research (What is "wellness" anyway?)

Grant program to promote positive health behaviors in underserved communities
(Sounds like attitude adjustment training: "Don't worry, be happy," I guess. Interesting that Senate Bill 319 already addresses this for women and children. Men, it seems, don't matter.)

Grant program for state access programs (These grants already exist, too!)

Grant program for national independent monitor pilot program for skilled nursing facilities and nursing facilities
(What is this? An independent monitor to "oversee" large chains of skilled nursing facilities for some defined period of time. What about Medicare's Nursing Home Compare program?

Grant program for training in dentistry programs
Already exists

Grant programs for innovations in interdisciplinary care (Yep, got this in place already, too)

Grant program for health insurance cooperatives
(Helpful cash for insurance interests

Grant program for wellness programs to small employers
(I can hear it now: "Don't drink, eat or smoke too much..." and place some nice posters on your wall...)

Grant program to disseminate best practices on implementing health workforce investment programs
(A bill already exists on the House floor: H.R. 2810)

Grant program for national health workforce online training
(looks like medical schools might be in trouble!)

Grant program for state alternative medical liability laws
(a grant to see if liability reform might work - fair enough - but will it change anything?)

Grant program for public health infrastructure
(um, don't we already have an Office of Public Health and Science?)

But the "demonstation project" that was created specifically for lawyers: Section 2537 (pg 1464) - a demonstration project of "grants to medical-legal partnerships" was most concerning.

What's this you ask? Is it for health care?

Not really. It's actually a grant just for lawyers who practice poverty law so they can "assist patients and their families to navigate health care-related programs and activities" for the next five years. Never mind that's why we have doctors, nurses and social workers.

Bottom line, there are plenty of places this bill could (and should) be cut to save costs.

But hey, when it comes to health care reform, it seems there's something for everyone when the taxpayer's paying!

-Wes

Quiz of the Day: The Distance Traveler

2009-11-10T06:30:00.005-06:00

Q: What's a hundred years old and has traveled over 5 million miles?

A: Would you believe a basketball?

-Wes

Where Treatment Guidelines Fall Flat

2009-11-10T05:55:00.010-06:00

... when cases don't follow the rule book:

All of the planned means of tackling Stellan's SVT today during his ablation failed initially. Heart block was induced each and every time from each and every angle they tried to ablate. Dr. A and his team were left with little choice but to ablate Stellan's AV node in order to get rid of his accessory pathway. But before they did, one of Dr. A's colleagues threw out a wild idea.

"Let's try to go through his aorta."

Not in the plan. Not even in the possible or hypothetical plans. Not considered safe or feasible or wise on a 10 kilo baby. But with few options left before destroying Stellan's node, they decided to risk it.

To be honest, I'm glad I didn't know about it at the time.

So from his groin, they threaded the catheter up into his aorta, down into his atrium and through his valve toward his ventricle. From that angle, even though Dr. A said they were in the exact same spot as they'd tried ablating earlier, there was a money shot. He tried cryoablation. It started to zap his SVT with no heart block. So he tried a little more cryo. Again, no heart block.

So Dr. A pulled out the big dog. The radio frequency ablation catheter. His ultimate goal was to get 2 to 3 seconds of ablating done, even if it destroyed his node.

1 second. 2 seconds. 3, 4, 5.

From that angle, through the aorta, Stellan's AV node remained untouched.

Unbelievably, Dr. A was able to crank up the wattage and ablate Stellan's extra pathway for one solid minute before declaring his pathway dead on arrival.

And his AV node is as happy as the day is long.

Certainly this case didn't "Get With the Guidelines" and might not be the approach most would take in this circumstance. Huge risk was involved for the pediatric electrophysiologist: a higher incidence of stroke for the child, unknown long-term affects to the aorta, a potential to injure the coronary arteries, and a large risk to one's professional career if anything went wrong.

At yet, the doctor considered all other options and did what he thought was best for the child given the circumstances...

... then hit a home run.

And judging by the picture of the child in the referenced blog's sidebar, it looks like the doctor did a pretty fine job.

-Wes

h/t: A faithful reader.

Bloggers Can Make a Difference on Veteran's Day

2009-11-08T21:56:00.012-06:00

Meet the Eleven Eleven Campaign -- a nationwide campaign by BeyondTribute.org to change the way America honors its Veterans by hoping to raise $11 from 11 million Americans beginning (when else?) but November 11th.

To learn more about the campaign and how you can help make this November 11th a day when bloggers come together to support our Vets, join the conference call Monday, November 9th at 8 pm ET/7 pm/CT/5 pm PT.

Please RSVP to the conference call here:

http://action.eleven-eleven.org/t/5400/signUp.jsp?key=2817

Dial-in Number: 1-213-289-0500

Participant Access Code: 4670471

-Wes

h/t: Glenn Reynolds at Instapundit.

220-215

2009-11-08T05:41:00.009-06:00

House Bill 3962 passed by the narrowest of margins.

I find it interesting that when others parse the implications of the bill's passage, doctors aren't mentioned.

Kind of says it all.

-Wes

Criminal Penalties For No Insurance Possible Under Pelosi Bill

2009-11-07T11:11:00.005-06:00

From a letter from the the non-partisan Joint Committee of Taxation from Rep David Camp to explain penalties for not carrying insurance under the Pelosi Bill (H.R. 3962):

Americans who do not maintain “acceptable health insurance coverage” and who choose not to pay the bill’s new individual mandate tax (generally 2.5% of income), are subject to numerous civil and criminal penalties, including criminal fines of up to $250,000 and imprisonment of up to five years.

Is this what American's want, criminal penalties including jail time?

If not, I'd suggest you call, fax, or e-mail your Congressman today.

-Wes

Reader Poll: Should House Health Care Bill Pass?

2009-11-07T10:00:00.000-06:00

With the US House of Representatives set to vote on the ‘‘Affordable Health Care for America Act’’ (H.R. Bill 3962) this weekend, should the bill pass?

Vote in the sidebar and feel free to leave any comments you'd like to make below.

-Wes

P.S. I'm not tracking URL's nor marketing - promise - just interested what others who read this blog think.

Cardiology Consolidation Continues

2009-11-06T16:48:00.004-06:00

This time, in Kansas City:

Cuts of the magnitude envisioned by Medicare, Holkins said, would present “a significant problem for the revenue side of our business model.”

The 14-physician practice, which has roughly 80 employees, has been independent since its founding in 1975.

So, Holkins said, the decision to affiliate was not taken lightly.

“I have really liked the idea of being independent,” he said. “But I also like to be able to pay our employees well and have enough left so our physician partners make a comparable salary to their peers in Kansas City, and I saw that as something I would not be able to do going forward.”

-Wes

Reading the Fine Print of Government-Run Comparative Effectiveness Research

2009-11-06T12:08:00.009-06:00

This week, the New England Journal of Medicine published the comparative effectiveness research trial "ROOBY" comparing conventional cardiac bypass surgery to off-pump bypass surgery. The study was conducted at VA medical centers and randomly enrolled 2203 patients between conventional bypass and off-pump bypass surgeries. The study concluded "At 1 year of follow-up, patients in the off-pump group had worse composite outcomes and poorer graft patency than did patients in the on-pump group. No significant differences between the techniques were found in neuropsychological outcomes or use of major resources." Excellent reviews of the trial (with associated surgeon commentary) are provided at theHeart.org and at MedPageToday.com.

What I found interesting was the fact that over half of the operations in the trial were performed by surgical residents. (Admitedly all surgeons had to have a minimum experience of 20 off-pump procedures, but the median off-pump experience by surgeons in the trial was 50 procedures.)

I wonder, where were the senior surgeons at the VA?

-Wes

Cancer's Miracle

2009-11-05T23:04:00.004-06:00

It's a strange thing, cancer.

It renders the greatest intellect impotent.

Families coalesce, grapple, then muster their courage to confront the reality, their angst cloaked in platitudes and favors. Certainly there must be something we can do!

Slow. Gradual. Relentless. And yet it's moving too fast.

I wake at night to my wife's restlessness, the thoughts of her mother circulating. Why her? Why now?

A sniffle, a sigh. There is little I can do.

The relentless march goes on, the cadence quickening.

We realize now what's important; her mother's gifts to us a gem.

-Wes