Saturday, August 20, 2011

Blogging About the Workplace

I've noticed a lot of confusion both from my coworkers and bloggers on the internet about what is "work appropriate" blogging. Basically a lot of workplaces (including my own) have updated code of conduct polices to reflect rises in social media. Basically the policies are pretty ridiculous. For example, I cannot post about my workplace on a personal blog where my name and workplace can be connected. This means on my facebook account I cannot say "I work for company X" and then make a facebook post saying how much my boss is a complete retard. Even if I don't name my workplace or boss, I still have my workplace listed elsewhere. That allows someone to make the connection between me and company X. Management can fire then me at this point.

Fortunately I am aware of this and I don't publish my real name or workplace on this blog. Also in the healthcare field privacy is incredibly important and I would never jeopardize anyone's personal information. Any names or dates you see here are altered to protect privacy, even though they are true events. Companies are asking for this same right to privacy. I think consumers have a right to know everything they can about companies they choose. That's why I like to post about how hospitals work so you, the consumer, can stay informed.

Monday, August 15, 2011

Whether or not to Admit a Patient

Hospitals all over the world have a tough time deciding which patients should be admitted to a hospital floor from the emergency room. This is because risks, insurances, patient comfort, room availability, and doctor recommendation are all involved.
Hospitals frequently are overcapacity.
1. Risks are associated with this decision because if a patient becomes worse after being admitted then the hospital is liable for this (i.e. hospital acquired infection, pressure ulcer). The hospital then will treat the patient with no reimbursement and a red mark from the government on patient safety.
2. Insurances are very tricky on whether they want you to be admitted. Admitting costs a lot of money, but an insurance company can't deny a doctor's recommendation to have you admitted. Unfortunately they have a work around, which is where they will arrange to send you to a cheaper hospital via ambulance. Also they may arrange to have doctor's from their cheaper network to provide care for you and the follow up treatment. These less expensive networks aren't always less effective, indeed many hospitals over charge insurance companies to cover their other costs. This is especially true with the rising number of for-profit hospitals as opposed to faith-based and/or non-profit hospitals.
3. Patient Comfort: Some patients want every test imaginable. I had a patient not long ago complain his lip briefly hurt. He demanded to have it checked out by an MRI and the doctor gave it to him because he didn't want to deal with the patient. This means the patient had to be checked into the intensive care unit overflow and monitored 24/7. Patient ended up eventually being discharged for simple vertigo after a couple days.
4.  Room Availability: This is a key factor because if there are no rooms available, ambulances and people are going to be directed to other hospitals. This is when people who really don't need a room are going to get scooted out the door pretty quickly. This is also when non-urgent people are going to see wait times skyrocket. Basically if you are still conscious, you are still going to be alive in the next 10 minutes. Some people won't be. Even if you've been there 2 hours with a broken leg, if someone walks in through the door complaining about chest pain they will get treated first.  If it is slow however, you may find more non-urgent people admitted for both patient safety, and to make some money.
5. Doctor Recommendation is the trickiest of them all because doctor's all have very different admitting practices. Some (usually older) doctors never admit and some younger ones always do (safest option). This is also how patients can be admitted against their will. More and more young doctors are choosing to admit older/intoxicated patients against their will. This has to do with changing times, laws, and liabilities over the past 20 years. For example, I was treating an elderly woman with dementia who had picked a good chunk of her skin off. The woman was getting ready to go home (she was very alert, just would forget things occasionally) but the social worker had actually allowed the daughter to get power of attorney and the doctor had decided she wasn't alert enough to make medical choices. She was admitted against her will for a week and then transferred to an elderly care facility.
Does it come down to money?
In my area several respected hospitals have been accused by the government of milking government insurance programs. They have defended themselves by saying this enables them to cover less fortunate people and to maintain hospitals in low-income areas. Others have said they are doing this for profit and not philanthropy. I'd say its a bit of both.

Sunday, August 14, 2011

CNBC: "Health plan rules: What counts as an emergency?"

CNBC published an article last Tuesday about how insurance companies (and the government) bill you on emergency room visits. For example, if you go to the ER for a stuffy nose, your health insurance may not cover your visit because it could be treated with over-the-counter remedies. Also, the chance of you actually dying or becoming disabled are very slim from a congested nose. So why do ERs take these patients and run so many expensive tests? Why can't they tell them to go to a 24hr pharmacy and grab NyQuil? Or to follow up with their personal doctor/urgent care?

There are a couple reasons why an ER can't do this from a legal perspective. For one, nose congestion is a symptom of many illnesses, some of them dangerous. If the ER discharged you without running tests, it would be liable if you died from an infection over the next 24 hours. The hospital would risk lawsuits both from the family and the government. At an urgent care, personal doctor, or health clinic doesn't have as much responsibility when it comes to treating you. They have the disclaimer "if you get worse, go to the ER".

Generally though, insurance companies are very good about covering ER visits (and hospitals are good at getting them to cover it too). Insurance companies know their customers aren't always good at determining what an "emergency" is, but they may try and provide more education in the future as costs rise with technological advancements in medicine.


Saturday, August 13, 2011

Update 8/13/2011

Hey all,
Making a late post here. I am pretty much exhausted from last nights 12hr shift and am now home. I'm hoping to catch some sleep before I go back in this afternoon. So let's just say I had a 330 pound drunk/cracked out guy that just wouldn't cooperate. Actually, now that I think, about it had a quite a few drunk or otherwise intoxicated patients yelling for no reason. Basically a crazy night. So that's all for now! I'll post something tomorrow morning.

Friday, August 12, 2011

ER Question: "Why the Long Wait?"

Many people are concerned with wait times in ERs. It is an "Emergency Room" so why aren't you always treated immediately? Not just in the lobby, but also once you get to a room. Think about it this way, there is a long sequence of events before you can be treated. A delay in any one of those steps can cause other delays. Let's take a look what's going on while you are waiting for treatment.

1. Checking in: When you first enter an emergency room, you check in at the desk and are soon sent to triage. Triage determines your priority for an ER bed. They may give you a colored wrist band, or assign you a color in our computers (people get mad when they see their low priority). In triage, we take your vitals like blood pressure, heart rate, pulse oximetry, respiratory rate, and your chief complaint (what you are seeking help with). After this, we assign you a color. Red is immediate (suspected heart attack, stroke, aneurism, etc.), yellow is delayed, green is minor, and blue is our nice way of saying really, you're fine. If you came in on an ambulance, you usually skip this step because ambulances don't transfer unless it is urgent.
2. At the Room (Part 1): So now that you have finally been given a room, why haven't you been given meds? The nurse will usually draw some blood and start an IV. IVs (intraveneous therapy) are hollow needles with tubing that are placed directly into a vein on your arm. This enables fast administration of meds or to set up a IV pump/drip.  The drawn blood will to the hospital lab for testing (drug test only if there's suspected abuse). These tests determine blood components like white cell count, platelets, red blood cells, dehydration, diseases, etc. In addition to this, you may receive X-Rays, EKGs, MRIs, etc. at this point.
3. At the Room (Part 2): Great! So now they've thoroughly tested you. Where is the doctor? Well most docs don't like treating until they've seen all the test results. Some blood tests or cultures can take up to 2 hours. At this point, the doctor will come in and ask you some questions about your diet, exercise, health history, and habits before leaving again. He can then allow meds for pain, anxiety, blood pressure, etc. because he has had the "face-to-face examination". The nurse will then administer the meds, or an ER Tech may perform a splint, or finish bandaging. The doc may also call specialists like neurologists, cardiologists, internists, plastic surgeon, etc. for consultation. After you have stabilized, the doctor takes a last look at you, writes out a few prescriptions, and then the nurse goes over paperwork with you.
4. Discharge: You are free to go and we certainly have a lot of other people to see!

While you will be asked for identification, next of kin, brief history of your complaint, and medical insurance, you will always be treated regardless of your ability to provide all of these things. If you receive a bill, you may want to apply for money from the government and or your insurance company (or both). Your bill will generally explain this.

Thursday, August 11, 2011

First Aid Tutorial: Splinting Broken/Fractured Bones

Most people will experience a broken or fractured bone in their lifetime. When left untreated, they can heal improperly causing pain and loss of movement. However, with proper knowledge, broken bones are relatively easy to stabilize. For the purposes of this tutorial ,we will basically cover treatment for the first few days of a skeletal injury. That is because ERs typically treat broken bones with temporary splints and then forward patients to see a specialist. Yet, what happens when you break a bone Friday afternoon and you can't see a specialist until Tuesday? That's where this tutorial is gonna save you. Many people do not know the difference between a splint an a cast. So what is a splint?
This is a leg cast.
This is a leg splint. 

Why the difference? Because when you initially break or fracture a bone, you may experience severe swelling over the next few days. If we gave you a cast right away, then your leg or arm could swell up so much that you could lose circulation. No circulation could cost you the whole arm or leg. By leaving some "breathing room" the extremity can swell a little and you still have blood flow. However, a splint is temporary and recommended for 3 days until the swelling has passed and you can see an orthopedic doctor.

SO someone walks up to me with a broken wrist (or almost any bone). How do I treat it?
1. Observe: It is important to pinpoint where the injury has occurred. The most simple solution to this is to ask the patient, "Where does it hurt?". Also examine for any additional injuries, a grating sensation (broken bones rubbing against themselves), or strange angles in the bone. Also make sure the patient is staying conscious and not entering shock. If they are having trouble breathing, it is your priority to stabilize that first. Shock will kill a person much sooner then broken bones.
2. Wound Care: If any bones are protruding out of the skin, you will need to apply a sterile dressing to cover the opening and an ice pack to reduce swelling. Elevating the extremity is also very useful for swelling.
3. Bone Realignment: This is what we always see in the movies. Preferably with a partner holding the extremity, you need to pull gently on the injured extremity until it enters a neutral position. While painful at first, patients will experience a huge sense of relief afterwards as the bones, veins, arteries, and nerves straighten out. If this is NOT done, then the splint will cause further damage or the bone could heal improperly. If any strong resistance is felt, then you need to stop and splint as close to a neutral position as you can.
4. Assess: Check for the 5 P's (pain, pallor (color), poor circulation, paresthesia (numbness), pulse, and paralysis}. This is important because we will need to check these AFTER applying the splint to make sure it isn't too tight.
5. Splinting: This is widely regarded as a very creative process. There isn't a right or wrong way to splint, so it is kind of an art form for us EMTs. You can use anything from a piece of wood to a soccer shinguard. The important thing is we are wrapping the extremity to a stable surface so there is no chance it will be moved after realignment. Wrap the injured bone as well as the joints above and below so they cannot move. At this point also cut/remove any jewelry such as rings.
6. Reassess: Recheck the 5 P's (Step 4). If they have had some pain relief and still posses the same level of function, then this person is well on their way to recovery.
Notice that the top and sides of this splint are
SOFT bandage. The bottom is hard fiberglass bandage.

Following up with an orthopedic specialist is always recommended to ensure proper healing. Always see a professional if you think you may have broken something, but this tutorial can assist you in emergency situations and if you are far from a hospital.

Wednesday, August 10, 2011

L.A. Times: Violence afflicts ER workers

The L.A. Times recently wrote a report on violence against ER workers. The article was for the most part very well done. It listed several high profile cases over the past years and a brief description of what happened. It included a 2009 drunk patient who chased nurses with scissors. A gunman in 1993 who opened fire on an emergency room. Unfortunately, I can tell you first hand that these so called "high profile" events are all too common. It was actually just last year a hospital 30 minutes from me had a "Code Silver". A Code Silver is a hospital code stating an armed and dangerous person. This was NOT a drill but luckily they talked down the gunman into giving up. Still other oddities occur like suicide attempts (sometimes by visitors), as well as people try to falsify that they are a doctor. The L.A. times gives a survey that says 40% of ER workers were assaulted over the last year. This number is almost certainly higher and and the average level of assault is high as well.
Patients are frustrated with wait times
but our hands are tied.
The L.A. Times is correct in pointing out that most attacks are done by people who have an altered mental status. An altered mental status could be anyone who can't think straight (disease, drugs, mental illness). A lot of people don't realize that hospital ERs are essentially dumping points for drunks, drug addicts, and psychiatric patients. Drunks are problematic because their judgement is so impaired they make very bad choices, like attempting to pee on your leg while you stand with your back turned. Or they can certainly be more violent. After several of our own high profile events, my hospital requires that all psych patients have a constant sitter. When our supervisor can't find someone to come in and do it, you guessed it, that responsibility falls to me or my coworkers. Psych patients are difficult because they are very unpredictable. We can't restrain or medicate them until they are aggressive (which is often too late). Also, once they get dumped at an ER, the psych wards often won't take them back. We have had psych patients (adults AND children) wait days before we could find them a proper care facility.
Psych patients are often unpredictable.
So how bad is the problem really? You have to understand that at the end of a 12 hour shift, the last thing you want to do is fill out pages and pages of an incident report about how an 84yr old patient with dementia suckered punched you in the face. Then you have to go down to employee health and wait for a few hours. Even if hospital unions try to cash in on this issue, many hospital are not unionized and their effectiveness will be minimal at best. So it may be awhile before we have numbers showing just how bad it is.