Emergencies and the Rational For Our Treatment Algorithm

We are a primary care medical office that tries to deliver personalized attentive care. We define emergencies as chest pain, significant breathing difficulty and loss of consciousness, uncontrolled bleeding or pain, sudden change in mental status and behavior or major trauma. In these situations, my office staff receiving a phone call interrupts me so I can speak with you and determine whether or not to advise you to call 911. We do this because we know with life threatening situations time is of the essence.

Emergency Medical Services at 911 can arrive within 5 minutes. They are all Advanced Cardiac Life Support (ACLS) trained and carry the equipment and medications to provide life sustaining care while you are transported to a hospital Emergency Department that has the staff, medications and equipment to keep you alive while we diagnose the problem and create a plan to rectify it.

The office staff is trained in Basic Cardiac Life Support. We do not have a defibrillator. We do not maintain and store medications to correct low blood pressure – cardiac arrhythmias. We do not have endotracheal tubes to intubate you and breathe for you. In the past, when we tried to maintain these supplies, they became outdated due to infrequent use and were expensive to replace. Since we do very few resuscitations day to day we are not as experienced or efficient as EMS and emergency department personnel are.

I realize the wait for care and institutional care settings are not pleasant. We sacrifice that for the best chance to keep you healthy. Trust me, it is no fun cancelling a scheduled patients to run to the ER and then return already behind. We do it for your comfort and security and safety.

In the recent past patients with chest pain resembling heart disease, trouble breathing and excessive bleeding have refused to call 911 and were upset when we did not bring them into the office. We do this for your health and safety not our convenience. If you would like to discuss this feel free to contact the office.

Customer Satisfaction and the Quality of Your Health Care

CMSThe Center for Medicare Services (CMS) has issued edicts and guidelines to hospitals that their customer satisfaction survey ratings must improve or else they will be fined and penalized.  One of the areas where they want improvement is in the emergency room or department.  They now require ER’s to make a disposition and either treat you and send you on your way or admit you to stay within three hours (180 minutes). On the surface anyone who has spent time in an emergency room cannot possibly object to speedier more efficient service so why am I objecting to this new regulation?

For decades emergency rooms have practiced the art of triage. Triage means they treat the sickest but most salvageable patients first.  Those with simple non-life-threatening issues and those with severe issues but no hope of survival get placed at the back of the line in deference to sicker individuals with problems that require immediate attention if the patient is to survive. Emergency Rooms have become everyone’s after hours and weekend primary care office for many reasons. They are jammed with minor health problems and social issues that in an earlier less litigious era would have been treated at home by family and friends or seen by the family doctor in the office or in the past in their homes. Many of the reasons for these visits would have been treated with guidelines and instructions available in any Cub Scout or Brownie First Aid instructional manual but today clog the ERs.  Should an abrasion from a fall to the arm of a 12 year old receive the same immediate attention as a change in mental status and collapse of a previously healthy 45 year old father of three?

CMS has not differentiated between University Hospital Centers with fulltime on-site interns, residents and fellows and community hospitals where few if any of the treating physicians are on location full time.  In order to stay in compliance with these draconian rules, community hospitals are diverting doctors and nurses from caring for patients in the facility to the emergency department to “move patients along.”   Our community hospital initially imposed a “thirty minute rule” which said that when a community based physician received a phone call from the ER that a patient required admission they had 30 minutes to admit that patient.   Admitting a patient without seeing them, taking a history and doing an appropriate examination is not in the patient’s best interest. When the medical staff was asked to approve this rule as part of the Medical Staff bylaws, they overwhelmingly rejected it.

Everyone wants prompt, efficient, courteous attention and service especially when ill. CMS and this administration are trying to implement it by decree without true consideration of how their actions will impact patient care. One size does not fit all.  Without citizen outcry to their elected officials, poorly thought-out policy in the name of cost savings will impact you and your loved ones unless you speak up.

Coordination of Care Requires Patient Input

As a general internist with a small concierge practice I have tried to coordinate my patients’ care and dealings within a complex, bureaucratic and dysfunctional health system. Patients have access to me 24 hours a day, seven days per week by telephone, cell phone, email and text messaging.  I do not have an answering service so all after-hours calls are forwarded directly to me.   During the initial patient orientation visit we discuss the need to keep me abreast of their health concerns and problems so I can bring the big picture to their immediate and localized health concern or problem.  Similar information goes out in my quarterly newsletter and is on my web site. I am trying to reach the technologically sophisticated patients as well as the technologically challenged.

I was somewhat surprised to receive a late Friday night call from the local ER to tell me one of my 86 year old cognitively impaired individuals was being evaluated. When I spoke to the charge nurse I found that the patient was brought by the paramedics for intractable nausea and vomiting.   This particularly charming, mild to moderately cognitively impaired, woman had moved with her 90 year old husband from her private residence to a senior facility on my suggestion so that care was available for her as she deteriorated and required more hands-on attention. They were thrilled with the new apartment as well as the care and concern provided by the staff.  I had seen the patient six weeks ago and she was doing fine. There was no mention of problems.

Since her last visit she had developed a dental problem. Unknown to me, her dentist extracted all her left lower jaw teeth and made arrangements for a periodontist to perform three dental implants.  The periodontist pre-medicated her, one hour before surgery, with 1 gram of the antibiotic amoxicillin because seven years ago she had a surgical knee replacement.  She then had the surgery and was sent home on Tylenol and codeine for pain.

She took her second Tylenol with codeine at home, went down to the community dining room, ate some chicken soup, felt ill and vomited several times.  The dining room staff just called 911 and transported her to the local ER.  I was called by the ER doctor after his evaluation to say he believes that between the large dose of oral antibiotic and the codeine, the patient became nauseated and vomited. He was prepared to give her some intravenous fluids and send her home.  After completing the IV fluids she got up to go home, became lightheaded and had another bout of emesis.   I was called back at about midnight and went in to evaluate her.  She looked fine but a bit dehydrated so I decided to observe her overnight while administering fluids and anti-emetics if she needed them.

I had no previous knowledge that this cognitively impaired woman with a limited future lifespan was having such extensive dental surgery.  There is much controversy about whether an individual with a prosthetic knee replacement even needs antibiotic prophylaxis with an antibiotic notorious for causing GI distress.  There were additionally concerns on my part about the choice of a codeine based narcotic for pain control based on her existing medication list.

Had the husband, patient or dentist called in advance to discuss this we could have come up with alternatives that may have prevented this hospitalization.  If the primary care physician is not included in the care plan and kept current, how can one be expected to coordinate care?

After evaluating the patient and making the arrangements for her to stay overnight, I expressed my disappointment to the patient’s spouse about not being informed of the impending dental procedures of this magnitude in advance.  He apologized profusely for not thinking to call me or asking the dentist to call me. He asked me to write about it in my blog to let the other patients know why they need to keep their doctor informed of all their health care comings and goings.

It’s Only a Cold …

As a concierge medical practice we pride ourselves on being available to help our patients with access to the doctor by phone and same day appointments. At this time of year we are faced with daily phone calls regarding cold or flu like symptoms.  Thus, I thought it appropriate to share some topical information which should be useful in helping anyone decide whether they should “ride out the storm” or give their doctor a call.

There are at least 1,500 different known viruses that lead to a viral upper respiratory tract infection sometimes known as “the common cold”.   With these, a high sustained fever of 101 degrees Fahrenheit is rare.  Aches and pains, nasal discharge with runny nose and post nasal drip are common. Dry cough advancing to a barking cough productive of clear, yellow and often greenish phlegm is common as well.  You’ll most likely feel miserable. Your sinus and head congestion make you feel like you are in a tunnel, a sound chamber, or wearing a deep sea diving helmet. Your appetite waxes and wanes. You are exhausted with the activities of daily living.  Getting out of bed to wash your face and groom yourself may seem as challenging as a 26.5 mile race up a hill.

Currently, there is no cure for the common cold. Antibiotics do not work.  A “Z Pack “does not speed up the process. An injection of antibiotic does not make it go away faster. The infection could care less if you have a high school reunion to go to in Philadelphia, a grandchild’s bar mitzvah or baptism, or a flight to Paris for a combined work/pleasure excursion. Frankly, once you have this type of viral infection you will most likely have to ride out the storm.

Furthermore, going to the ER and sitting and waiting to be seen doesn’t make the infection go away quicker. Paying for a visit at a walk in center or urgent care center where you are more likely to negotiate successfully for an unwarranted or needed antibiotic will not help either.

In most instances, your recovery from the virus will take 7-14 days providing you drink plenty of warm fluids, rest when you are tired and use common sense. Cough medicine may ease the cough. Saline nasal solution may clear the nasal congestion. Judicious use of a nasal decongestant under your physician’s supervision may help as well.  It will take time. You are contagious. No you should not go to the gym if you are feeling poorly. Chicken soup, tincture of time, hot tea with honey, plenty of rest and common sense are recommended remedies.

If at any point you still feel you have the plague, dengue fever, the bird flu or the Ebola virus come on in. We will take a look, evaluate your symptoms and likely tell you, “It’s a cold.”

Deep Vein Thrombosis Prophylaxis, Safety and the Joint Commission on Accreditation of Hospitals

Over the last few years, great emphasis has been placed on preventing blood clots from forming in the legs and pelvis of all hospitalized patients. These blood clots can break off and travel to the lungs causing life-threatening breathing problems and fatal heart arrhythmias and sudden death. Preventing these “venous thromboembolic events” has been a priority of quality organizations like the Joint Commission on Accreditation of Hospitals which inspect hospitals and offer certification if the hospital meets their criteria.

The movement to prevent these clots and sudden death has become so strong that you cannot admit a patient to the hospital without addressing these issues. Physicians must either choose to give injections below the skin with the blood thinner heparin three times a day or the low molecular weight heparin twice a day. You are additionally asked to prescribe mechanical compression stockings to the legs to further reduce the risk.

If you choose not to institute these orders you must clearly write out and outline your objections and reasons for not taking these measures. Even if you document your reasons for not instituting these measures you’re assured of receiving a call from your hospital’s quality care organization.

This all becomes newsworthy because two recent studies called into question the practices. One study concluded that mechanical compression stockings added nothing to the use of blood thinners in preventing deep vein clots. The other study cited that for every 1000 patients treated with blood thinners to prevent pulmonary emboli; you prevented three non-fatal pulmonary emboli at the expense of causing nine bleeding events – four of which are major.  I suspect this data will be discussed in our medical journals and at scholarly meetings and a consensus opinion will be reached on how to proceed. Letters will be written to journals criticizing the methods of these studies and other letters will be written defending them and, ultimately, a common sense approach will be reached.

In the meantime, it would be far more interesting to look at the Joint Commission on Accreditation of Hospitals and determine how they got so powerful that they can mandate procedures which may not have any value and may do harm?  Who are they?  How do they generate income and how much goes to who and why?

It is a fact that in the state of Florida, private insurers like Blue Cross Blue Shield, Aetna, Humana, will not contract with a hospital or institution unless it receives certification from this organization.  A study should be done to see if these JCAHO inspections costing $7-8 million dollars every other year resulted in any reduction of in-hospital errors, iatrogenic illnesses, death rates and serious illness?

Insurers and employers who pick up the “lion’s share” of our health care costs are always asking for accountability and efficiency and want to pay for what works. It would be nice to know if their relationship with JCAHO has made the patient safer or healthier over the last 15 years.

The 20 Minute Rule

To meet Federal patient satisfaction goals, our hospital administration is requiring community based physicians to give patient admission orders before we have a chance to see the patient. Patients who self-refer themselves to the emergency department, are evaluated by the emergency room staff, and who are determined to require admission must be admitted by their community physician within 20 minutes of receiving a call from the ER staff advising the patient requires admission. In most cases, the community physicians have no idea the patient is actually at the ER until they receive that call.

It is bad medicine to issue patient orders on a patient you have not seen, taken a history from or performed an examination on. To complicate matters, the hospital does not require physicians to actually come in and see the patient for 12 hours after admission.   Think about it, diagnostic and care orders are being given routinely by doctors who have not examined the patient. The doctors then have the latitude to not show up for half a day to actually do an onsite evaluation.

One of the cardinal rules of medical training is you should do a thorough history and exam before constructing a theory of the causes of an illness and instituting diagnostic and therapeutic measures. The local hospital rule is a direct effort of the hospital to control all aspects of patient care for financial gain. They are buying up practices, revamping medical staff bylaws by manipulating the rules and, filling the decision making committees and legislative physician groups with salaried doctors they control.

Hospitals perceive community based physicians who are advocates for their patients as a threat to their financial planning.  The goal is to drive out the community based physicians because they act as a check and balance to the designs of the hospital system working as advocates of their patients. Do not believe for one moment that the goals and aspirations of patients in a community setting are aligned with the goals and aspirations of hospital administration.

I recommend that citizens look into the politics of their local hospital system.  If you do not, you may find that your doctor can no longer take care of you when you are sickest and in need of those professional services provided by someone who knows you well. You may find that you are transported from the ER to the floor quickly but you may not get to see a doctor for half a day.

How should this policy be altered to make sense?  Staff physicians should have 90 minutes to arrive at the ER and assume the care of their patients. In critical life threatening situations requiring immediate intervention, hospital ER staff should be providing stabilizing care until the patient’s care team arrives.

Requiring doctors to give orders on patients they have not seen is bad medicine. Giving those same doctors 12 hours to show up is irresponsible.