Phlebotomy Venipuncture Bruise Picture of My Arm

It has now been two years  of writing myself TSH prescriptions and heading down to the laboratory for a phlebotomy venipuncture of my arm.  What have I learned?  I've come to the conclusion that experience doesn't mean jack for phlebotomists. Why do I say this?

Because I've had some fresh new phlebotomists venipuncture my arm with no problem and no pain.  I've had others claim to do it for years and dig around like it's their first time.  

Here's a picture of my arm after  my last phlebotomy venipuncture.

Phlebotomist:  I've been doing this for 30 years.  You won't feel a thing

That's a lot of  confidence to have lady, considering that  you  gave me the largest phlebotomy venipuncture hematoma in the history of my short lab life.    I used to donate plasma while in medical school for a little extra money.  

I'd just grab a book and go down for a couple of hours and study while all the near homeless, borderline alcoholic and  tobacco stained public poured in from the bus stop to sit  in their captain's chair  and watch  Jerry Springer while big business leached them of their dignity.  I thought of it as an opportunity to mingle with my future patient population. 

During those couple of years of donations, I developed a small needle track on my arm.  You can see it clear as day in my picture. I can always tell which of my patients donate plasma by that single  identifying mark in their antecubital space.  Or else they are  drug addicts and they use plasma donation as their excuse to lie to their physicians.

  

I always tell the phlebotomy people to do their venipuncture through that scar.  They can't miss.  Ever. It's like a gastroenterologist doing their upper endoscopy but missing the mouth.  Or the cardiologist doing an LV gram with the cathther in the left ventricle, but missing the left ventricle.  You just can't miss.  Ever.  It's impossible.  Just do the phlebotomy venipuncture through the scar and everything will be fine. 

No.   Not this lady.  She's confident in her skills.  She decides to take a medial approach and jab me in no man's land.  Thirty years she's been doing this.  It might as well have been three hours.  

I don't know what kind of phlebotomy venipuncture schooling  or training is required to do this kind of thing. A search of Amazon shows fake venipuncture arms for sale.   Maybe that's how they train.  Maybe they should make some of the these models fully equipped with plasma donation landmark scars  for all those really experienced ones with all the confidence.

Nigerian Bank Scam And The Crazy Medical Consequences You Never Thought Of

A reader sent me this story about a patient of hers several years ago.  It's unbelievable.  It involves, a Nigerian bank scam, a mail order bride and the unintended medical consequences of FREE=MORE.

I'm sure none of you have ever met a victim of the Nigerian bank scam.  I get hundreds of these emails a year.  It wouldn't even occur to me that someone would.  But this story makes me think twice about the mental capacity of Americans in general. 

Every now and then Happy's local news outlet interviews a victim of the Nigerian bank scam.  Still.  After all these years, the Nigerian bank scam still makes headline news.  They always muffle the voice and black out the face. I'm not sure if the victim does this to protect their ego or if the television station does it to protect their story against other scam artists looking for an easy target.  

I suppose these Nigerian bank scam victims must feel pretty embarrassed.  When the whole world knows about these scams, and either laughs at or ignores them,  except the victim,  it's hard for them to find a compassionate shoulder to cry one.  You just know their close friends and family  are all thinking the same thing.

I'm sure a lot of them don't tell anyone about their gullibility. They take their secret to their grave.   I'm sure a lot of them wished it would all just go away.  Perhaps those who fell victim to the Nigerian bank scam might break down into the thralls of depression or anxiety.  It probably puts strain on their marriage.  Some adult children might even try to put mom or dad into a nursing home for allowing the Nigerians, probably laughing in the back of a boiler room, from stealing their inheritance. 

Well, here's the story of one such Nigerian bank scam victim,  and the medical consequences of his extreme case of FREE=MORE.  Thanks to my reader for this incredible story.

I was called down to the Emergency Room in the middle of the night to see an elderly man for fevers. He was a nice gentleman -- a bit confused but generally an accurate historian.  He stated that he’d not been feeling well for a week or so.  His symptoms consisted of nausea, loss of appetite, occasional diarrhea, and occasional fevers often with drenching sweats.   Over this time period, he’d become so fatigued he couldn't do his activities of daily living without help.  The  ER physician had ordered all of the usual labs, X-rays, and urinalysis but was left without a definitive diagnosis.  And here’s where I (the hospitalist) entered the picture.

I began my routine line of questioning which was consistent with that obtained by the ER staff (it does happen sometimes).  The answer is always urosepsis or pneumonia, so I figured this 2 am admission wasn't going to be any more exciting than that.    After reviewing the chart and looking at this sickly appearing man, I had a gut feeling that there was a lot more to this story that would ultimately tie up the diagnosis.  As I’d used up most of my “routine” questions, and the UA and CXR were clear, I began to delve a little deeper into the patient’s social history.  No kidding.  The social history.   For all the students out there, don't get too excited about doing a thorough social history on all your patients.  You're wasting your time. And don't let your instructors tell you otherwise.   Social history serves little purpose than to meet, as Happy likes to say, the requirements of the Medicare National Bank.  

In  my ten years as a hospitalist, the only two social history issues that have ever mattered were smoking and alcohol status.  But not this time.  I delved a little deeper and what do you know.  JACKPOT!!!!

Information poured out like a river. The incessant talking at 2 am, the stuff that usually just wastes my time, was actually helpful, this one time in ten years.  He began by telling me that he was married to a much younger woman whom he had “ordered” via mail from a  former Soviet Union republic.  As a women, I have to admit, she was hot.  Damn hot.  He showed me pictures of his proud new wife.  She was apparently quite happy with  him as well. But he felt that he wasn’t able to properly care for her due to his poor financial situation. 

So what does he do?  A couple months after the blessed union, he received an email telling him that he had unclaimed monies amounting to nearly $17 million US Dollars.  The catch:  all he needed to do was forward $12,000 to a bank account and then travel to Africa where he could claim his money.

You guessed it!  Not wanting to disappoint his bride, he did exactly that -- paid his $12,000 and promptly boarded a plane to Africa to find his fortune.  Because he knew he had $17 million dollars waiting for him in Nigeria,  he only purchased a one-way ticket to Africa and planned to fly back 1^st class with his new-found wealth.  Unfortunately, when he arrived in Africa there was no money – he’d been duped by the notorious Nigerian bank scam artists.  Yes folks, the one everyone knows about.  Without any money for the return trip, he was forced to wait a few days in Nigeria  for his beautiful and faithful wife  to transfer funds via Western Union. 

Shortly after arriving home his symptoms began. 

I couldn’t believe what I was hearing.  Was this guy was for real or just plain crazy?  Perhaps what he needed was a psychiatry admission.  Who could make this stuff up?   His story was so outrageous, it had to be true, right?  At that point, I recalled something from my residency training -- “You’ll never find it if you don’t look.”  Therefore, like a good internist, I ordered another test – a peripheral smear.  Low and behold he had malaria.  Freakin' malaria.  This is America.  Who the Hell gets malaria?  I guess the patient wasn’t crazy after all.

 There's not a lot more to say about this story.  I could go into the life cycle of a malarial infection but that would be boring.

• Nigerian bank scam.  Check
• Mail order bride.  Check
• Malaria.  Check

Poor fella.  I' hope he's doing better. God has a strange way of making us stronger.

Health Care Reform Grand Rounds Edition

Go check out this weeks edition of Ground Rounds, all about Health Care Reform.  You won't be disappointed with this weeks excellent selection or readings.

Doctors' Day 2010 Lunch and Breakfast: What Did You Get For Your Special Day?

March 30th, 2010 is  Happy Doctors' Day.  That would be today.   What did I get for my special Doctors' Day?  I have written previously about gifts for doctors.  But today, I got a beautiful personally signed card from all the administrators.   And all the doctors at Happy's hospital  got food for their Doctors' Day.

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Dialysis Survival Gene Discovered, I Think

As a hospitalist physician of seven years,  taking care of dialysis patients who never seem to die, I've come to the conclusion that a dialysis survival gene exists out there.  I think I'll call it the Happy Gene.    I talked with one of Happy's nephrologists the other day about dialysis survival. Here's what they said:

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March Madness 2010 Final Four Hospitalist Bracket: The Social Nightmare Dominates

The writing is on the wall. This year's First Annual March Madness 2010 Final Four Hospitalist Bracket has  been dominated by the social nightmare.   We skipped right through the Elite Eight with few surprises.   Now, let's take a look at Final Four action, shall we.

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Electrical Neuromuscular Stimulator vs The Hand: What Giving The Finger Really Means

If you ever want to ride your motorcycle without a helmet just remember this story.  Every week I'm asked to admit quadriplegic patients.  Quadriplegics who got that way, out of their own fault, for  not wearing their helmet.

The reasons they get admitted are always the same.  They either have pneumonia or UTI with sepsis or they have a problem with their bowels.  And you'll never guess what the nurses will have to do to you. It involves either an electrical neuromuscular stimulator more likely the nurse's finger.

Remember, without a functioning nervous system, everything stops working the way it should. Quadriplegics often come into the hospital with twenty or thirty medications or more.  All of them function in one way or another to do what a failed nervous system can't.  

Constipation is a big problem in quadriplegic patients.  Some of them need aggressive digital rectal stimulation (not to be confused with milking the prostate).  That means stimulating the anus to induce a bowel movement.  And some of them require upwards of 45 minutes to an hour of rectal stimulation to induce a bowel movement.

Some patients are very particular about this process.  It makes me wonder if they use it for some sort of sexual gratification or if it really is necessary to induce a bowel movement.   Should nurses be required to stand there for an hour and stimulate their patient for an hour while their other patients' needs go unmet?  Should hospitals purchase an electrical neuromuscular stimulator for use on the rectums of quadriplegic patients?  I don't know if such a thing exists, but it should.

How is a doctor or nurse to know if Mr Smith really needs an anal hand job or if he's just getting satisfaction out of the whole thing?  I have no idea.  Perhaps someone with experience could offer their insight. 

Is it reasonable to expect a nurse to stand there for an hour with their hand up a patients butt in today's day and age of patient volumes and documentation requirements and patient satisfaction requirments?  Perhaps the expectations should be muted.  Or  maybe there are unintended consequences on the good side unlike the unintended consequences of health care reform. 

How could this possibly be a good thing?  Exercise.   The nurse said,  "It's exhausting."  I found myself thinking, "That's exactly what exercise feels like".  I had a nurse once tell me she was upset about the smoking ban at Happy's Hosptital.  She said that walking outside for a cigarette was the only exercise she got on a daily basis.

How many calories an hour can a nurse burn by performing rectal stimulation on a patient?  I figured it's  probably mechanically similar to masturbation.  How many calories can you burn from masturbation?  A Google search says you can burn about 150 calories from a vigorous session of masturbation. I swear, that's what a Google search will tell you. 

If the nurse is really going at it, let's assume that 300 calories an hour can be burned from digital rectal stimulation.  If the hospital obtained an electrical neuromuscular stimulator, that's 2100 calories a week that could have been expended by the nursing staff had the hospital  let them do it the old fashioned way.

Just imagine how much weight loss in a year can be achieved by making the nurses do manual stimulation instead of buying a rectal electrical neuromuscular stimulator.   If we are going to make any headway at all in the cost of health care premiums, it's time to take a stand and enforce policies that are proven reduce disease.

And that means it's time to avoid those expense neuromuscular electrical stimulators and stick with the hand.  The next time you think you don't need to wear your helmet, thing about the nurses at Happy's hospital giving you the finger.  

Dickhead T-Shirt (Picture). Now. That's Just Good Humor

Brother Happy sent me this dickhead  t-shirt picture. Who wears this?

Patients Prefer Sexy Nurses To Competent Doctors Leading Hospitals To Fire The Ugly Ones

From the Tonight Show and the Jay Leno News Service comes this morsel of information about doctors, nurses  patients and hospitals.  According to Jay, a Men's Health poll indicates that 65% of men would prefer a sexy nurse over a competent doctor. 

That's shocking but not surprising.  I suppose it  takes a lot of pressure off the doctors  for a perfect hospital outcome.   Unless of course the nurse happens to be ugly.

I can see it now.  In an effort to improve patient satisfaction and reduce malpractice risk, hospitals  just need to fire the ugly nurses and keep the hot ones.  In fact, as a hospitalist, my malpractice risk depends on it. Forget about all the other quality improvement junk we put ourselves through.

I'd put my money on hot nurses every day.

How The Health Care Reform Debate Got Started

....it wasn't until 2008 when a little known typo during committee debate  quickly shifted the discussion from hair care  reform to health care reform.  And now you know how the health care reform debate got started. Want to see Happy's mug shot on his new television appearance?

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Returning Broken Christmas Lights Can Be A Pain So How Do You Get Your Money Back?

Over the years I've learned my lesson over and over again.  Christmas lights break much quicker than they should.  And returning broken Christmas lights can be a pain.  This year I decided to do things differently.  Over the years I've learned that most stores will not return holiday merchandise for the price you paid for it.  If you are returning broken Christmas lights, you will usually only get back the clearance price, if they'll even take it back at all.

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Who Has Access To My Medical Records? I Do

Have you ever asked yourself the question:  "Who has access to my medical records?"  It's supposed to be secure.  Your medical records are supposed to be protected.  For many people, they don't want anyone knowing they have genital warts or that they were treated for depression five years ago.

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The Woman Is Always Right Version Of Grand Rounds

Check out this week's offerings from Grand Rounds, woman style.

Sam's Club Food Means Date Night Is Every Night

Mrs Happy and I have discovered Sam's Club food as the eighth wonder of the world.  Specifically their four berry sundae.    The Sam's Club four berry sundae has blueberries, blackberries, strawberries and raspberries on top of a delicious vanilla soft serve.  Two can dine for $3.21.  It doesn't get any better than that.  

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Am I Having A Heart Attack? Self Test Kit Now Available And What That Means For Hospitalists

Am I having a heart attack?  From the files of the strange and unusual comes this home self test kit for myocardial infarction, otherwise known as a heart attack.

 

For the lay people out there, a heart attack occurs when blood flow to the heart muscle stops, usually because of a blockage in the arteries around the heart (the coronary arteries).  It's what happened to Bill Clinton, although his heart muscle didn't die, as it likely had collateral blood flow from other arteries.  When blood flow stops the heart muscle dies.  When the heart muscle cells die, they  release compounds into the blood stream which can then be detected on blood draws.  That is the basis for detecting a heart attack by drawing blood.  There are some compounds that are specific to the heart, such as troponins that will only go up when the heart muscle is dying.  Other enzymes, such as the CK go up with any muscle damage, including the heart.

That is the basis of this new self test kit for heart attack testing from China Sky One Medical that tries to answer the "Am I having a heart attack" question, from home.    It was approved in China in 2007 and recently received European Union clearance as well.  Read more at  medGadget

I can just see it now.

Scenario #1:  Patient watching Oprah.  Patient starts having chest pain.  Patient gets out her home heart attack self test kit.  Patient lances finger and places blood onto strip.  Plus sign shows up.  Patient can't remember if this was a pregnancy test or the heart attack kit.  Patient goes to the emergency room stating they are either pregnant or they are having a heart attack.  Patient gets triage into the psychiatry wing and the hospitalist gets called to see a "soft admission" for psychosis.

Scenario #2:  Patient watching Oprah.  Patient having chest pain.  Patient gets out her home heart attack self test kit.  Patient lances finger and places blood onto strip.  Negative sign shows up.  Patient refuses to believe she isn't having a life threatening heart attack.  She does it again.  It's still negative.  Patient angry now that she isn't having a heart attack and decides to go to the emergency room anyway because she says she's having a heart attack.  Patient is now angry that nobody believes she's having a heart attack and strikes out at the nurses.  Hospitalist gets asked to come see a soft  hospital admission for psychosis.  

I can't see these kits offering any benefit to patients.  For hospitalists, it's job security.

Toyota Brake Problem Solved! See The New 2010 Toyota Corolla In Action

In case you hadn't heard, the Toyota brake problem has been solved.  Meet the new 2010 Toyota Cowrolla.  That's just good humor.

The Bureaucratization Of Porn And What It Means For ObamaCare

The quote of the day comes from this entertaining, yet frightening display of government's power grab into your everyday life (assuming you're a porn star).  If you find it ludicrous that a broke California still has the resources to regulate sex orgies, just  wait until ObamaCare rears it's ugly head.  You'll want to head for cover.

What Are The Tax Implications Of Health Care Finance Reform?

Now that your government plans to spend three trillion dollars (but only admits to 940 billion) over the next decade on health care, where is all that money going to come from?   You guessed it.  It's tax and spend economics at its finest.  What are the tax implications of health care finance reform on your wallet?  Here's a concise and well written summary of the tax implications of health care finance reform coming your way.  It's an excellent read and I highly recommend you check it out.  

Three key tax implications for couples earning more than $250,000 per year in AGI and individuals earning more than $200,000 in AGI per year

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Is The Health Care Reform Constitutional?

The fight isn't over. In fact it's just beginning. Get ready for Constitutional challenges to the health care reform bill. Is this health care reform Constitutional? Here's a nice piece over at the Washington Post by a constitutional law professor from Georgetown University.

He has lots of great angles from which legal challenges will be made. One challenge I  found intriguing was whether our  government can will you to engage in an economic transaction with a private company simply for being alive.

That's a great point. Does the government have the power to force you to buy something simply because you are alive? If that is true, what prevents the government from mandating that everyone must also buy a casket, funeral plot or urn for your ashes.

Or maybe that's next.  This health care bill isn't over by a long shot.  In fact,  the fight is just beginning and many questions will linger as to whether key portions of the mandate are even Constitutional.   What do you think?  Should the government have the power to force you to buy something you don't think you need or want?

March Madness Sweet 16 2010 Hospitalist Bracket Results Are In

I'm not sure how you're doing in your 2010 March Madness office pool. You might even be winning. However, there are a lot of games left to play. So take a breather and check out where the real action is. The Sweet 16 March Madness 2010 First Annual Hospitalist Bracket has now been completed. 

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End of Life Ethical Issues: When Doctors and Nurses Are Forced To Perform Futile CPR On a Patient With a Dead Heart

 The horror of it all.  It was one of the most inhumane situations I had ever been placed in as a physician. Where  end of life ethical issues took a back seat to a warped legal driven fear that consumed physicians and nurses alike  at the expense of allowing a compassionate natural dying experience.  There is a fear of  legal retribution that drives doctors and nurses to create great pain and suffering at the hands of irrational families with unmanaged expectations.    

 

I've been a hospitalist now for seven years. One of my responsibilities as a hospitalist is to respond to all code blue situations, otherwise known as cardiopulmonary arrest.  The code team usually consists of a doctor (hospitalist or emergency room doctor), advanced cardiac life support nurses (usually from the hospital's intensive care unit), a charge nurse who documents the sequence of events, a respiratory therapist and even a pharmacist.  Many students from all walks of life will also get hands on experience in these high octane situations.

 

Many factors determine whether someone will survive a code blue situation.  Recently, we saved a woman after she aspirated into  into a pulseless electrical activity rhythm.  After ten minutes of resuscitation, we got her back, only to have her die several days later. Some patients and families understand the realities and limitations of the human body.  Just the other day, one guy died peacefully in his sleep after living with emphysema the greater part of his adult life.

And then there are the end of life ethical issues which arise when families have lost all touch with reality.  Such as performing futile CPR on a dead heart.  There were seven intravenous drips running through her  heart to try and keep her alive.

She was definitely at the end of her life.  After several massive heart attacks in recent months, she was left with an ejection fraction of under 5% from  which to maintain perfusion to all the organs in her body.  For all intents and purposes, she had a dead heart, with just one small thread of a coronary artery surviving her years of hard liquor and tobacco abuse.

But her heart was not her only issue. If cardiogenic shock wasn't enough to initiate compassionate end of life care in this  woman, she also had anuric renal failure and was on continuous dialysis.  Not to mention she was also in septic shock from severe bilateral pneumonia and required four vasopressors to barely maintain adequate perfusion pressure.  The nail in the coffin was her serum albumin level of 1.3, which itself  is a life threatening prognostic indicator. 

She was the epitome of end of life.  Her care was futile. You can't get any closer to death than this lady did.  And her family wanted everything done.    That's what their mother would have wanted, they said.  They demanded full support at all costs regardless of the therapeutic expectation for recovery.  It was really quite sad.  Dialysis?  Of course.  Intubation?  Not an after thought.  Chest compressions?  The thought of stopping never crossed their mind. 

I couldn't be more certain of her imminent death. I indicated that death was imminent and no reasonable physician could expect another physician to continue full supportive therapies or to do CPR on a dead heart.  It was simply inhumane to code a dead heart.  A dead heart.  A DEAD HEART!  Just having this discussion seems  asinine to me.  The fact that anyone would even contemplate such an action speaks volumes 

She coded again.  Again and again.  The code was futile.  The whole thing was ludicrous. Coding a dead heart.  A DEAD HEART! I kept saying it over and over again out of disgust for the whole situation. She coded again, and again, and again.  Over the course of an hour, she coded five times, and every time the nurses ran in doing chest compressions and pushing epinephrine, despite the fact that she was already maxed out on an epinephrine drip.  All because the family wanted everything done.

After hard fought  negotiations with the family, they agreed that should she code again, the only appropriate end of life ethical decision would be to let her pass in one peace.  And when she coded again, I had to stand there and watch my patient's son holding her hand,  surrounded by a massive pile of IV poles, a ventilator, a dialysis machine and ten other nurses and doctors while she slipped back into ventricular fibrillation.  And what were his  last dying words for his mother?  Were they "I love you mom"?  No they weren't.  They were:

Son:  Can't you just shock her one more time?
To which I responded
Happy:  No sir, I can't.  Your mother is dead.

She left this earth without an ounce of dignity.  As a whole, our  fear of end of life ethical issues allowed her son to demand a medical assault on her soul to a degree I had never seen before.  It was the worst end of life experience I had ever seen.  

Smokers Linked to Lower IQ. Research Suggests They Really Are Just Stupid

The verdict is in.  Smokers don't smoke because of social or economic reasons.  Smokers smoke because they  have a lower IQ.  To put it politically incorrectly, that makes smokers just plain stupid.

And the more you smoke, the dumber you are.  At least that's what research out of Israel suggests.  If you smoke five packs a day, you must be as dumb as a bag of rocks.

The data suggests that smoking won't make you stupid or lower your IQ, unless of course you are one of the lucky ones who end up drooling and pooping in your own bed after a massive stroke or get anoxic encephalopathy from your massive out of hospital cardiac arrest.  In that case, the smoking will drastically reduce your intelligence.

 People with lower IQs are the ones who tend to be smokers

.So the next time you see Uncle Charlie or Aunt Wilma taking drags off  their cigarette, tell them how stupid they are and that you have the research to prove.  Perhaps they'll admit to you that they really are just too dumb to quit smoking for good.  

Being poor doesn't make you smoke. In fact, the Hispanic women in our country are some of the poorest around.  What percentage of Hispanic women smoke cigarettes? About 10%, which is less than half the rate of our general population.     

Being poor and uneducated doesn't make you smoke.  Apparently, having a low IQ and being stupid does.  Which, unfortunately, might make it even harder to quit smoking right now. 

March Madness 2010 Round 1 Hospitalist Bracket Results: The Last Patient Standing

Here you have it folks. Everyone in the world has probably filled out their own March Madness 2010 College basketball tournament bracket with the hopes of striking it rich in the office pool. But I bet nobody has filled out their own hospitalist bracket.

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Why Did My Bonsai Tree Die?

Growing a bonsai tree is not easy.  In this case, my bonsai tree has died.  Why did my bonsai tree die?

Because these things suck water and if you forget about them for a day or two, they'll die on you.  In this case, after a week of diversion, something had to give.  In this case the end result was a dead bonsai tree.  Sorry mama Happy.  I think you'll understand.  Lesson learned.  No more bonsai trees for Dr and Mrs Happy.  May you  rest in peace little dead bonsai tree.

What Did You Eat On St Patrick's Day?

What did you eat on St Patrick's Day?  I passed on the corned beef and cabbage and went straight for the Mexican with family.    

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2010 Residency Match Results Are In

As you can guess, it was a dismal year for family medicine with US graduates filling only 44% of available slots. Internal medicine was close behind with only 55% of slots filled by US medical graduates. Where do the rest come from?

We import the rest from other countries with doctors looking to play the doctor labor arbitrage. This is an embarrassment to our country. Our students are the brightest in the world. And they know when to avoid a bad economic deal when they see one.  The question is, what are we going to do about it?

Enjoy reading over this 2010 Residency Match result.

NRMP 2010 PDF

Super Morbid Obesity: Woman Proclaims "I Want To Be 1000 pounds"

From the super morbid obesity files comes this unbelievable death wish.  According to Fox News, Donna Simpson from Old Bridge, NJ has one incredible goal in life.  Already topping the scales at 602 pounds, her desire is to be the best at what she does, eating.  Her goal you ask?  She wants to weigh 1,000 pounds.

She wants to become the worlds fattest woman.  Oh, and she has a three year old child she will never see grow up.  And she doesn't buy into the idea that she is unhealthy.

In America's land of freedom, we hold dearly our rights to self determination.  We might say that this woman, already of super morbid obesity status, has every right to eat her self to death while the American tax payer fits the bill for her disabling illnesses that, if not already present, are already on their way.    This is slow suicide.  She will die an early death, just as smokers do.  She is committing suicide, even if her actions don't represent an immediate risk to death.  Just as smokers do.

What does Donna have to say for herself?  She already uses a motor scooter while grocery shopping because she can't walk more than 20 feet.   She is one of those internal medicine opportunities I wrote about:  The Patient's of Walmart.   I'm sure she doesn't have a shopping cart full of fruit and vegetables  spending $750 a week to eat 12,000 calories a day and staying as sedentary as possible so she doesn't burn any calories.

You might ask yourself how someone supports themselves financially when they can't move 20 feet without panting.  Well, she has found a way to cash in on her super morbid obesity status.  I have to give her credit for making an effort to earn a living, but this is unbelievable.  She appears on a website IN A BIKINI, where men watch videos of her gorging on food.  She has about 265 followers paying her $16 a month to watch her eat.  That's about $4,000 a month. 

I would presume that this high end video production website doesn't offer health insurance.  I would also be pretty accurate to make an assumption that she probably gets disability because of her  super morbid obesity.  Perhaps she's already on the Medicaid roll. I'm certain she is probably uninsurable by every imaginable standard.  

So where is the personal responsibility in all this? If she is already on the take for government assistance, do tax payers have an obligation to provide for all her medical needs?  Does the patient have any responsibility to care for her body in a way to minimizes her assistance on public resources?  This is the great American question we find difficult to answer.  Where does personal responsibility begin and end?  And what is the role of community resources when personal responsibility has failed. 


In America, we clearly place freedom of personal choice above social solidarity.     But we also  expect society to pay for the failures of individual responsibility.  A recent attempt in my  state to implement random drugs of abuse testing and the removal of Medicaid for one year on those who tested positive for illicit drugs was met head on by a camp of left wing fanatics claiming the illegality and irresponsible nature of such a plan.  I shake my head in disbelief at what our society has become.  We want the freedom to do what ever we want.  And we want others  to pay for the consequences.

The freedom fighters would say that this woman, who is the poster child for super morbid obesity, has every right in the world to define how she lives her life.    And I agree with them.   I could care less  what she does on her own free will.   I would also say that as the mistress of her own domain, she then has the responsibility to fend for herself when everything comes crashing down.  As a society she should have no expectation of support of any kind from health care to housing to a home nurse or even a nursing home.  Personal freedom gave her the rights on the way up.  Personal freedom gives her the consequences on the way down.

Some people might say she has a mental illness, either diagnosed or not, that excuses her from her actions. There is no way a super morbid obese woman already at 600 pounds would gravitate to 1000 pounds without some sort of mental problem.  

I agree she has a mental illness.  I disagree that it excuses her from her actions.  If she still has the capacity to make poor medical decisions, she has the capacity to change, regardless of her mental illness.   We don't excuse depressed people from murder charges.  We shouldn't excuse depressed people from eating themselves to death.  I think this lady has lost touch with reality.   But so have all smokers who take in  4 packs a day and make bold statements proclaiming their right to independence.  

The real question here comes down to whether we as a nation value our freedom to engage in irresponsible behavior with the expectation that our nation will collectively pay for it or if the individual has a responsibility to minimize their reliance on the resources of others by taking responsibility for their actions and how they live their life.  

In this super morbid obese lady, I have no doubt in my mind that she will cost taxpayers untold  millions in resources to try to keep her alive when her day of reckoning comes due.  

Some people try to argue that her early death will  actually be a good thing because it reduces her reliance on other community resources such as Social Security and Medicaid.  To that camp, I say that we  should then simply stop Social Security and all other welfare programs now and allow Americans to fend for themselves.  If in fact an early death is beneficial to our nation's bottom line, then I say lets simply stop spending any money at all.   All it does is keep people alive longer.   If the economic success of our country is measured by an early death, we can accelerate our financial strength by simple cutting off the resources all together.

Watch the incredible commentary at the end of this video that tells it like it is.  They hit the nail on the head.  American freedom at its finest.

For other great weight related posts visit

• Weight loss options:  The Greatest FAIL ever.  
• Non surgical weight loss options for one pound an hour!
• Try the tongue patch weight loss plan.  
• Losing weight one pound at a time through public display.
• Three Clicks Weight Loss Blog.  Unusual motivation to lose weight. 
• My 120 pound journey:  An inspirational weight loss journey.
• How lose weight after pregnancy (video).

Talking To Strangers Can Be An Eye Opening Experience

Mrs Happy and I went to Orlando earlier this year to get away from the crazy cold and snow we've been having this year.  It was a wonderful trip.  We took in a day looking at the Kennedy Space Center where we saw the space shuttle engine and launch road.  We also took a video and picture of an armadillo while we were there. 

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Shopping Cart Full of Fruit and Vegetables

Here's a picture of a shopping cart full of fruit and vegetables from our shopping cart the other day.  How much did all this nutrition cost?  Let's see

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Iggy Pictures of Marty and Cooper

More pictures of Marty and Cooper, our two Iggys.  The white one is Marty sleeping in the sunshine.  That's also Marty in our laundry basket.  They love warm cloths.  If I have a pile of warm laundry on the bed, they'll crawl right under the whole thing.   The third picture is Marty laying on his back.  He's like a little baby.   Then we have Cooper playing with his squeaker.  The last Iggy picture is also Cooper sitting in his new dog bed.  He loves anything new.  He's got a 100 squeaky toys, but if you show him a new one, that's his new favorite.  Here's his new favorite dog bed.

If you enjoyed these pictures, you can see several hundred pictures in my slide show in my sidebar.  You can also find all my posts I've tagged of Marty and Cooper's escapades near the bottom of my middle sidebar.  I've also got a lot of movies of them in action which you can reach by clicking on my video bar in my menu of options at the top.  Enjoy their shining beauty.

By the way, Mrs Happy filled out our 2010 census.  She included one white child and one black child in our household.  

Athletes In Action: Cool Special Olympics Video

Check out these athletes in action in this cool Special Olympics video

How Does Spiriva (Tiotropium) Work ( Mechanism of Action)

A reader asked me this question:

How does Spiriva work (what does it do)? I read the stuff on it, but my eyes glazed over. Can you put the cookies on the bottom shelf for this lay person?

Well reader, here's your answer:  

Spiriva, or Tiotropium,

competitively and reversibly inhibits the action of acetylcholine at type 3 muscarinic (M₃) receptors in bronchial smooth muscle causing bronchodilation. 

If you have any other questions, just let me know.  Just kidding.  In lay persons terms there are several ways to attack  the treatment of asthma or COPD.  You want to open up the airways leading from your mouth to your lung tissue and you want to reduce the amount of inflammation that can cause your airways to spasms and shut down.  You need your airways open and free of inflammation to allow the easy passage of oxygen in and carbon dioxide out.  The steroids help cut down inflammation which can reduce their propensity to spasm.   Smoking is an irritant and makes them spasm all the time.  Steroids are  often given IV acutely in very high doses, and orally sub-acutely and inhaled on a long term basis. 

There are several classes of drugs which help open up the airways. These are called bronchodilators.  One class works on the beta-2 specific smooth muscle receptors in the airways to cause them to dilate (short acting albuterol and long acting salmeterol (Serevent) or long acting formoterol (Foradil)).  The other class of drugs works on a class of acetylcholine receptors to cause bronchodilation (short acting ipratropium or long acting Spiriva).  Both drugs attack the same problem from a different mechanism in order to open up the airway

These drugs are often put in combination with each other

• Duoneb nebulizer (albuterol (Ventolin) + ipratropium (Atrovent))
• Combivent (duoneb in inhaler form)
• Advair (Salmeterol + fluticasone steroid) long acting agent
• Symbicort (formoterol + budesonide steroid) long acting agent
• Tiotropium (Spiriva) long acting agent

These newer long acting drugs are expensive.  Often times hospitalized patients will get started on them and then told to continue with them on discharge.  Unfortunately, many of these newer long acting agents can run upwards of $150 or more per month.  Are they better than the generic short acting agents?  Do they offer any addition protection other than convenience on a cost axis?  I don't know.  I haven't reviewed the literature for quite some time.  I do know they can be difficult to approve on some formularies and many patients have difficulty paying for them.

The thing that I really think is silly  is that many patients come into the hospital on $500 more more worth of these inhalers a month while smoking one, two or three packs of cigarettes a day.  It's like a tell my smokers with heart disease:  We could throw every medicine known to benefit man at you from aspirin, ACEi, b-blockers, statins and Plavix, but if you continue to smoker, you're wasting your money.  You might as well right a check to Uncle Sam to pay down the deficit instead of going to Walmart every month to pick up your meds.

At least you'd save some gas money.

Grand Rounds From A Tech Guy

Is up for you to see this week's greatest medical blogging offerings.

Bathroom Air Freshener Poll: Answer The Question America Is Dying To Know

Ok.  So I'm at work the other day and I see this Glade bathroom air freshener sitting in our private bathroom. And it hits me.  What is the appropriate bathroom air freshener protocol?  Take the poll and find out. 

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What Is There To Do At The American College Of Cardiology Meeting In Atlanta?

What is there to do at the American College of Cardiology meeting?  You can learn everything you need to know about the heart rates of partners engaging in extramarital affairs.  You can also learn how many mets it takes for a man to be on top.

Now that's a conference worth going to.  SHM, are you listening?  Enough of this junk science about insulin in the ICU.  I want to hear about sex in the hospital.

What Food Do Italian Greyhounds Like to Eat? See the Video.

Meet Marty and Cooper, our two Italian greyhounds.  Cooper, the grey one,  just turned six.  Marty, the white one,  turns seven in July.  They absolutely love their breakfast.  Marty in particular goes hog wild when he hears the bowls clanging as we put the food in it.

What kind of food do Italian greyhounds eat?  My sister feeds their Lucky dog, a 14 year old dalmatian,  an entire cupboard and pharmacy of food and medicine.  Sister, if you're reading this, feel free to explain Lucky's daily food and medicine routine.  

On the other hand, our guys aren't allowed to eat any people food.  They get Science Diet Adult Small Bites.  One large bag will last them about a month or so (between $35-$40).  We pour some warm water into the bowl of dry dog food to soften it up a bit and then we top it off with a little treat.  In this case, they each get  half a teaspoon of dried kelp sprinkled on top, purchased on Amazon from a specialty pet store that the breeder feeds her dogs. (about $20 every 3 or 4 months)  Who knows if it does anything healthy for them.  But they sure seem to like it.  

For a while there we had a problem getting Cooper to eat.  The vet told us to mix the dried food and water with our fingers to get our scent on the food and Cooper would be more interested.  Sure enough, it worked.  He was really skinny (if you can imagine that) for a while, to the point of looking like animal abuse.  But that seems to be done with.  Now they both dig right into their  morning breakfast food.  

When they aren't eating their breakfast, they nibble throughout the day in their normal dog bowl.    We leave their food out at all times.  But it seams they will only eat if we are watching them.  If we are gone all day, they will wait until we are sitting on the couch watching them eat.  And Cooper, always waits until Marty is done eating before approaching the bowl.   It's very sweet to watch how they interact with each other.

They are nothing but a big bowel of Angel love.  Enjoy the funny video showing what Italian greyhounds like to eat, Marty Cooper style.

If you want to see all their videos, click on the video tab in my menu bar at the top.  If you want to see all their posts, click on their "Marty and Cooper" tag in my middle sidebar or view hundreds of their pictures in their slideshow at the top of my middle sidebar.

Fastest Patient Exam Ever

This patient represents my fastest patient exam ever.  She'd been hospitalized for over two months awaiting placement in a nursing home. Nobody wanted her because she represented too great a risk to other nursing home patients.  It's interesting that a hospital with an emergency department can be forced to see every patient that comes through their doors, but every nursing home in this universe can refuse to accept any patient at any time.

This is an example of one of those patients that can take days, weeks, sometimes months to place.  They aren't safe to go home because they lack even the capacity to make poor medical decisions.  Their family abandons them with the mentality that it isn't their problem to fix.  The nursing homes don't care.  They have every right to pick and choose, just like doctors do as an outpatient.  No insurance?  That's a problem.   Bad insurance?  Bad disease?  Sorry, that's the hospital's problem.

A while back a patient was sued by a hospital because they refused to go to the only nursing home that would accept them.  The patient instead wished to stay in the hospital, I suspect forever.    Fortunately, the hospital isn't an appropriate place for long term management of stable disease. 

In this case, every morning this patient would pull her sheets over her head and sleep in peaceful seclusion.  Every morning she'd have nothing to say.  Every morning I would wake her up and interrupt her peaceful dreams.  Why?  Every morning I am required to write a note on her because hospital bylaws require a daily evaluation by  the attending physician. That' me, the hospitalist.  So every day I am required to do an evaluation, the depth of which is determined by me.  I can choose how much or how little I wish to do.  I let the circumstances guide my decision making process. 

After two months in the hospital, it becomes painfully  silly for me to wake her up every morning, pull the sheets off her head and ask her if she slept well last night.  So this time I didn't.  I asked the nurse if the patient had any issues or concerns.  I looked at the patient sleeping under her blanket from the bedside and I wrote my low level 99231 hospital follow up note

126/78  *  72  *  20  *  98.6

 Dementia, awaiting placement

That's my evaluation and it meets every lawful requirement necessary to be paid for by the Medicare National Bank for a CPT® 99231 evaluation without being accused of  fraud (which is why a hospitalist should almost NEVER bill a 99231) and it meets every requirement necessary by Happy's hospital bylaws.  And it pays about $35 from the MNB.

At least they aren't dead.  And I know this because dead people don't pull their own sheets over their head.  Although, as a resident working in the VA, I once had the privilege have being present when an RN documented stable vital signs on a patient that head been stiff dead for hours and hours and hours.

In that case, the RN failed to do a physical exam.  In my case,  this was the fastest patient exam ever.

You can find more about medical billing and coding in my hospital based coding lecture series.  

Quality Outcome Data Continues To Prove You Can Have Better Outcomes With Less Expensive Care

In the last year I have received two printouts showing me my quality outcome data as bench marked against my comparison population.  And the data continues to prove one thing:  I am a hospitalist  that  continues to offer high quality outcomes in a lower cost, higher  efficient style of practice.  My style of care is driven by one simple daily question which I ask myself 100's of times a day:

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Birthday Restaurant Song Video Reminds Me Of My Mock Cardiac Arrest

Here's a video of our ten year old niece getting her birthday restaurant song caught on video.  I can see the whole crew is filled with the joy and excitement of  their twentieth celebration show of the night.  Great job crew. I know you put your whole heart into it.

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The First Signs Of Spring Are Here

Italian Greyhounds Love to Run and Play

We love to take our Italian greyhounds, Marty and Cooper, to the park to play with other dogs.  Sometimes we have Italian greyhound play days where 40-50 Iggy's will play together.  That's an amazing sight to see.  This breed  loves to run. 

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Why Do Dogs Kick Out After Peeing?

We have two Italian greyhounds, Marty and Cooper, that bring such joy to our family.  They love to go for walks.  And they love to kick out when they're done peeing.  Here's silly Marty kicking out after doing his thing.  Why do dogs kick out after peeing?  I've been told dogs kick out like this after peeing as an instinctual way of trying to spread their scent farther.  I don't know about that.  I think they're just being ding dongs.  Here's a video below of Marty, our white Iggy,  kicking out after peeing. 

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Italian Greyhound Gives Hugs and Kisses (Cute Video!)

I bet you've never seen an Italian greyhound that gives hugs and kisses.  Marty is that dog.  Yes folks.  He's a hugger.  He loves giving hugs and kisses. And we have the video to prove it.

He'll plop his arms around your neck and give you a tiny little kiss.  He'll even push his neck into your mouth to get a  little kiss from you.  He's our little princess.  If you want to see more pictures of Marty and his brother Cooper, you kind find  his slide show in my middle side bar.  You can also find all his posts in my tag cloud and all his videos in my menu tab at the top of my blog.    Here's his video:

For more Marty and Cooper action, you can read all their blog posts, catch them at their YouTube channel  or watch their two beautiful slide show presentations, another full color slide show and the all black and white slide show, both available for viewing in my side bar as well.

Current Food Pyramid Subsidies: Vegetables Get Slaughtered

A reader pointed me out to this current food pyramid subsidy model showing what the daily recommended servings are for each category of food compared with how the federal farm subsidy programs actually work against the goal of a healthy nation.  You can click on the image to enlarge it and take a close look at how powerful lobby groups have become.

There is no reason why dairy and meat farmers should be getting 50 billion dollars in farm subsidies.  And if we are playing the subsidy game (which I think is a fraud), why are vegetables, one of the most healthy things we can put in our mouth, getting slaughtered at the table of entitlement handouts?

It's because of money in Washington, that's why.  Do you want your health care decisions being determined by a lawyer getting money from every which direction to stay in office.  I certainly don't.  Look at where our government spends our money and ask yourself how the power of money won't influence your health care needs.  It does and it will.  The question is, do you trust your representatives to do the right thing for you or for them.  Before we spend 3 trillion dollars on a new health care entitlement program, how about we first stop spending $50 billion dollars on t-bone steaks. If you want real change and a real bending of the health care inflation curve, the solutions exist not within the health care finance system, but on its periphery.   If we want a nation to eat from the current food pyramid, then we have to walk the walk .  Unfortunately, the money is too powerful .    Government subsidies are directly to blame, I suspect, for the fattening of our nation.  This is what happens when money and power drives policy. 

This current food pyramid subsidy says it all.  $50 billion dollars to eat meat.  What a waste.  Health care won't make you healthy.  Vegetables will.  Unfortunately, as the title of this picture says, a Big Mac costs less than a salad because your government makes it so.  Perhaps having millions  health care jobs  taking care of sick people who become sick at the bad economic policies of Washington makes for a good jobs report, but it won't do much for the long term health and economic sovereignty of our nation.  Unless we can get our population to start eating more salads and less Big Macs, we are all heading for the slaughter house along with the zucchinis and tomatoes.

HAARP, Haiti and Chile Earthquakes and Those Strange Lights Over Norway

I'm not much for conspiracy theories but could the Haiti and Chilean earthquakes, those strange lights over Norway a few months ago and H.A.A.R.P. all be part of a giant US government experiment to harness the power of our ionosphere?

Just Google "HAARP" and be prepared to wet your pants.  The ultimate weapon of mass destruction.  Maybe 2012 really is the end of the world.

Nurses Who Make More Money Than Doctors

" CRNAs were recruited at a higher pay than a family doctor

This is why we have a shortage of outpatient  primary care physicians in this country.  There is no other reason.  When you can make more income as a nurse than as a doctor, the laws of economics say so. 

Four year undergraduate degree + 2 year masters = $186,000
Four year undergraduate degree + 4 years of medical school + 12,000 hours of residency = $178,000

These economics have nothing to do with the value of the education and everything to do with the RVU system.  Incomes for medical  professionals who bill in a fee for service environment are entirely dependent on the RVU scale.  The RVU system  highly rewards the procedural  mentality of American medicine.  Therefor CRNAs are highly compensated.

If you think that CRNAs would get paid $186,000 because the value they bring to medicine is any greater than is the education and responsibility that  a family medicine physician brings, you're mistaken.  They are paid what they are paid because the interventions they do are highly rewarded on the RVU scale. That's the only reason. 

Hospitalist salaries on the other hand have left the constraints of the Medicare National Bank and their compensation is not restricted by the RVU medical model.  With an average per hospitalist subsidization of $100,000 per year, hospitals have found a friend in hospitalists who bring great hospitalist value to their bottom line.  Which is but one reason why I am The Happy Hospitalist. 

At some point, the whole idea of RVUs defining the value of each individual encounter is going to end.  It has to. Because it doesn't pay for what is valued.  It pays for what politics says it will.  RVU  is an unsustainable delivery model.  If we pay for what we value, eventually the trend will reverse.  If we continue not to pay for what we value, we will get exactly what we pay for: lots of CRNAs and no outpatient family medicine and internist physicians.  This is market economics applying the broken RVU system.   We have no outpatient internists because we have no outpatient RVUs.  The market does work with great efficiency.  In this case, the efficiency is not what we value, but it is what the market says it should be. So we are getting exactly what we pay for.  And for that, we should not be surprised. 

It's times like this that I'm glad I'm not only a physician, but an internist.  That might come in real handy when the health care implosion, already underway,  is completely unmasked by a debt that cannot be sustained by any rational measurement.

Space Shuttle Launch Road and Engine Pictures at the Kennedy Space Center

We recently got back from the Kennedy Space Center. In my previous post, you saw the armadillo sitting at the front entrance. Here's a neat picture of the space shuttle launch road that takes the shuttle from the hanger to the launch pad. I think this gravel road is seven feet thick.  See the rest




It takes a few days for the shuttle, attached to the launch platform, to move several miles down this road to the launch pad.  Look how big this road is compared to the normal road next to it. 

Each wheel track  takes up one of the entire gravel roads as the massive shuttle and mobile launch platform works its way to the launch pad.  The mobile launch platform is over eight million pounds without the shuttle and 11 million pounds with an unfueled space shuttle. 

And check out the size of the space shuttle engine.  Talk about a work of art.  These things are huge.  It's amazing .  These main engines weigh about 7000 pounds  and can generate 400,000 pound-foot of thrust.

Cool stuff.

Armadillo Video and Picture From The Kennedy Space Center

We took a return trip to Orlando last month.  This time we decided to spend a day at the Kennedy Space Center.  We'd never been there before.  It was something different to try.  On the drive up to the front gates we saw some alligators in the marshy ravine.  The signs also said there were deadly snakes in the area and  recommended we stay on the marked roads.  We even saw an armadillo.  This armadillo below.

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How Do You Bill a Patient Who Meets Inpatient Criteria, But Gets Admitted and Discharged On the Same Calendar Day?

ADDENDUM March 3rd, 2011:  I have since learned that patients who are admitted and discharged on the same calendar date are to use the global admit/discharge codes 99234, 99235 or 99236, whether they are in-patient status or observation status.  You can keep reading.  You might learn something else, but just keep this in mind when you are.


I recently took care of an 81 year old Medicaid patient brought in for pneumonia.  They came in around 4 am and I saw them at 2 pm the same calendar day.  Based on the patient's oxygen saturations on admission (85%) and their intensity of service (IV antibiotics), they met inpatient criteria by all reasonable standards.  My overnight partner appropriately billed out a 99223, the high level hospital admission code.

Except, by the time I saw the patient, they were 94% on room air.  They were feeling great with stable vital signs  and their symptoms had mostly resolved. So I made the a decision to discharge them to home.   The only problem is, what do I bill them as?  As physicians, most evaluation and management codes can only be billed once per day.  The patient can't have both an admit code (99221, 99222, or 99223) and a discharge code (99238 or 99239) on the same day.  No other code exists for me to bill their third party insurance.    No insurance will pay for an admission and discharge code on the same day.  So I billed it anyway. We'll have to see if it gets denied.   I have no other code to bill for the services I provided, separate and independent of the admission work provided.

Most of the time, when patients are brought into the hospital and discharged on the same calendar day, we have them in under observation status.  This is considered outpatient. They don't generally qualify for inpatient status.   We docs use it when we are trying to decide if a patient should be formally admitted to the hospital.   There is a giant book of criteria out there that most insurance companies use to determine if a full admission is warranted.  When patients are brought in and discharged on the same calendar day under observation status we use a set of codes 99234, 99235, or 99236, which includes the work of both the admission and discharge.  It is an all inclusive code, kind of a bundling of services. 

In this situation, my patient met criteria for inpatient admission and my partner appropriately billed the patient for such services. So placing her under observation status is not appropriate.  And using the observation codes would not be appropriate.   But that may not matter, as I found out recently with a physician review process.    If patients  get better quickly, due to excellent hospitalist care, our hospital may get dinged by only getting paid for the lower observation rate, even when they qualify for full inpatient status.   It seems to me that time is inappropriately being used in the equation to deny a hospital appropriate payment for services rendered. 

Because great care reduces length of stay, hospital reimbursement should not be sacrificed.  That sends the wrong message for providing quality care. 

I could have easily kept the patient in the hospital on IV antibiotics  for another two or three days of  continued inpatient care, which they very well would qualify as being medically necessary, because everything is medically necessary.  It always is.  That's why the process is a sham. 

But I didn't keep the patient in the hospital.  I took a risk and discharged an old lady who very well may fail outpatient therapy.  Or she may not.  My medical judgment says she won't.  But she may.  I don't have a crystal ball.  Only my medical experience.  I put myself at risk for the patient decompensatiing after discharge, perhaps leading to charges of negligence and not practicing under the standard of care. Any lawyer could find a doctor that says this patient should not have been discharged.  While I could find one that says they could.  Another reason why standard of care is a sham process for determining medical negligence. Because most medicine has no national guideline.  And the guidelines that exist have been heavily influenced and infiltrated by specialty societies with their own agenda. 

The whole insurance-doctor-lawyer triangle is a sham and it all leads to massive inefficiencies in our health care system. The patient has left the equation.  The daily internal battle with legal driven care and insurance driven care makes patient centered care nearly impossible.

I could keep a patient in the hospital to protect against charges of negligence.  It would be medically necessary and everyone gets paid.  In fact, I would get paid more by the simple act of daily fee for service.  Or I could discharge them and take the risk that  they get worse and the insurance company may claim that the whole inpatient admission was medically unnecessary because they got better so quickly.  How screwed up is that?

They must first get preauthorization for every lab, xray or prescription, no matter how big or smallHere's my solution. All insurance employees and all lawyers who practice med mal should be subjected to their own set of medical rules, so they can understand the effects their actions have on patients and doctors.  Their names and social security numbers will be entered into a national EMR data base  while employed in that capacity. For any contact with any physician or hospital

1. Once preauthorization is accepted, all labs, xrays and prescriptions must be approved by a committee of doctors, determined by doctors,  who gather to determine whether the order meets medical necessity and the standard of care of the committee.  Then, and only then, would the order be carried out.
2. The committee only meets during normal business working hours.  And they only meet once a day since, that's all they're getting paid for.  Providing multiple contacts during the day is uncompensated, and therefor, not considered necessary. 

I would give this one week before a health care revolution engulfs America.  That's how you fix American health care.

View the rest of my free lectures on medical billing and coding

LINK TO E/M POCKET REFERENCE CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital: (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic: (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high def view

EMR Comparison

Successful software implementation starts with choosing the right system. This  checklist contains over 50 of the most important features to look for when evaluating:

• electronic medical records
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Download now and get started today Other useful information is available at my EHR Resource Center.