Friday, October 24, 2008

I could never work in the ER

This is just another example of why I respect emergency health workers so much. It also illustrates why I could never ever ever be one.

I got a urinalysis on a three year old. The first two things I noticed were the bacteria and squamous epithelial cells. it's pretty clear she had a UTI. A three year old rarely gets a UTI on their own, although there are instances. A good portion of the time it's because of some kind of sexual abuse.

The next two things I noticed weren't so innocent. I saw sperm that was still motile, and Trichomonas. I can't begin to explain how extremely pissed I was about this. If you really want to talk about "never events" this is one that should never ever happen. This girl had obviously been sexually abused and given an STD. It had to have happened pretty recently for the sperm to still be motile.

If I were an emergency care worker armed with this information, I'd go apeshit. I can't imagine the kind of crap that I would do, especially if the abuser was around. I'm pretty sure whatever it would be it wouldn't be pleasant for him. I'm also pretty sure that I'd have a job for all of about two seconds after that.

Unfortunately things like this occur way too often and these emergency workers have to deal with this crap, and the scum of the earth daily. I can't imagine the professionalism and restraint that it takes to deal with this. So emergency workers I applaud you and your professionalism. I certainly couldn't deal with it.

Thursday, October 23, 2008

Cryo, and what it looks like

I took a pretty funny phone call in blood bank last night, it went a little something like this.

Nurse: Ummm, hi this is nurse blobity blob, I just came and picked up some cryo for this patient and it looks like it has a clot in it, there's this goopy white stuff in the bottom, I'm going to need you to set up some more.

Me: ummm, no it's not a clot. That's the actual cryo. The patient, considering her fibrinogen was ridiculously low, needs that "goopy white stuff."

Nurse: No, it's definitely a clot, I've been a nurse for 15 years and I know what a clot is.

Me: Well, you must not be a very good nurse if you don't know what cryo looks like, or even is, for that matter. I'm not thawing and pooling any more, B cryo is expensive and difficult to obtain, I'm not detroying ten units because you don't know what a clot looks like.

Nurse: I need to talk to your supervisor!

The nurse talked to my supervisor and frankly my supervisor is an idiot, She just wanted to appease the stupid nurse and waste a ton of product. It took every single tech working that night to tell her how stupid that was. It really worries me when a nurse doesn't really have any background information about what she's putting into a patient, it's really no different than if she were to push a drug without knowing the side effects or even generally what it looked like, according to the FDA blood products and drugs are basically the same thing.

Sometimes I wonder about these nurses, I don't mean to put down all nurses because our facility has some great ones, but we're also big enough that we have some WEEEETAAAAARDED ones. I hope I never get sick enough to be admitted, I've been a dick over the phone so many times that I know all the nurses would gang up and let me die.

Man I hope I don't have an email from one of the "important people" about this. The last time I had a problem in blood bank it involved a hospital vice-president that they called in at 3 in the morning, boy was that fun!

Tuesday, October 21, 2008

My boss is stuuuupid

I know this is only a small silly example of her stupidity/blind following of pseudo-regulations, but I'll share it with you regardless.

In our chemistry department we have three centrifuges, Two older, larger capacity centrifuges that run for 8 minutes, then we have a slightly smaller centrifuge that runs for 6 minutes. The smaller one is designed to be our stat centrifuge. and because we spent a ludicrous amount of money on it, we are to use it every time we have an ER.

That's all well and good unless your boss is a retard. I walked by the centrifuges to see if I could grab any samples that were just coming down. I see the stat centrifuge running with 5 minutes remaining. I see another ER sitting on top of the centrifuge while the other two weren't being used. I asked if there was a problem with the older centrifuges and she said; "no I just don't have any routine samples to put in." WTF?

I know in the grand scheme of things it only saves three minutes, but seriously, use you're fucking brain. I have a million stories about her that are much worse, but I thought this was the best example of her lack of critical thinking skills. I just don't get her, She was a salesperson for a major reference lab for the last 15 years, yet somehow that qualifies her to be a shift supervisor at a major trauma center that was voted the number 1 integrated health system in America. Who is she sleeping with?

Saturday, October 18, 2008

Blood and Cancer

This is a double post. One rant and one thing I'm actually happy about. Naturally we have to start with the rant.

There are a couple of floor nurses that are about to make me go apeshit. I work a third shift and my night starts at 10. Frequently we have units of blood that will expire at midnight. For years and years and years, as long as it was issued by midnight it was ok for use. The policy remains intact, yet a few nurses have taken it upon themselves to "educate" some of their patients. By educate I mean fill their heads with crap.

These Nurses are informing their patients that the units are going to expire at midnight and that the infusion will probably take longer than that. I don't know when we decided that a patient can pick and choose what unit of blood they want, but I guess these nurses have taken it upon themselves to allow this to be a decision. The expiration dates a largely arbitrary designed to mimic life cycles in vivo. There isn't a time bomb that's going to go off and make the blood suddenly useless or even less effective for that matter, it'll raise you're HCT and your HGB exactly the same way as a unit drawn 2 days ago.

It upsets me because it's a huge waste, at $400 a pop it's no small expense. It's tantamount to allowing a patient to refuse a medication because it expires that night. How ridiculous is that. All because a small group of nurses have decided unilaterally that these patients should be "educated."

We're a pretty large hospital. We have a contract with the local blood center to recieve short dated PRBC due to the high volume of infusions that we have. We're a last resort to make sure someone's donation is being used properly. I now have to deal with returning and destroying these units, and subsequently taking phone calls from Docs asking why it's taking so long to get Mr. so-and-so's blood transfused.

Anyway, The good news that you've all been waiting for.

Working third shift I don't get to stay in one department of the lab like other shifts do. It makes it much harder for me to become really good in any one area of the lab, yet I'm expected to be an expert for the night. Before I came to this hospital the only section I had ever worked in was the blood bank. about 2 years ago I cross trained in hematology. You remember basic stuff from school but it's hard to recognize and remember all kinds of crazy cells that you see from oncology patients.

We have one particular oncology patient that has been in our hospital for about the last year and in and out for the last 5. We save his slides for new employees and for students to look at, basically I've seen every abnormal cell you could possibly have in this patients blood. As I was saying earlier it's difficult to remain proficient in an area working there maybe once a week. During every morning run I do my best to pick this guys slide out of the pile and review it for myself to remind myself what some of these abnormal cells look like. You have to be the person driving yourself to become better at your job I keep up on my own continuing ed by doing things like this.

Yesterday morning I looked for his slide and couldn't find it. The first thing that came to my head, unfortunately, was that he had probably passed away, it's weird that I never new the guy but I felt like I did just because I saw his name so often and I kinda followed how he was doing.

I was doing a little investigating and found out that our system had autoverified his cbc. I asked for a redraw because I was sure it had to be a mislabeled specimin. I started to review his history and his slides had been more and more normal for the last month or so and it turns out it was the correct patient. So congrats Mr. Cancer. It's a big deal when a patient goes from 90% blasts to being within normal ranges so that an analyzer will autoverify your cbc. I'm really happy for this guy that I'll never know beyond a slide with a drop of his blood.

Thursday, October 16, 2008

How to really fix health care

I was watching the presidential debate last night and I came to one realization; either way, healthcare/coverage is going to remain extremely expensive.

Here's my plan to fix our entire system. I know this is an oversimplified plan but it is what it is.

Step 1. Eliminate JCHAO and any other government oversight programs.

There are hundreds if not thousands of private certifying agencies of health professionals in the U.S. For the lab two major ones are the A.S.C.P. and C.A.P. Both of these private/privately funded organizations have the expertise to do a better job of oversight and certification. The added bonus these organizations provide is that they don't use tax payer dollars. The only government oversight committee that would be needed would be a 25 member team that would review each hospital throughout the year and ensure they have up to date certifications from these private agencies.

Step 2. Allow hospitals to reject non-emergency patients with no insurance without fear of lawsuits.

There are far too many people that abuse the healthcare system and there is no good way to prevent them from continuing to abuse the system. We need to allow our emergency health workers, the EMT, the ER nurse and the ER Doc to make educated decisions based on the need for care. If someone comes in complaining of a cough x 2 days, they don't need to be seen let the triage nurse send them home without seeing a provider.

Step 3. Eliminate federal medicaid

Change the medicaid system to a state run system that takes federal money out of the equation. Maybe more people will be up in arms if they really see the abuse that happens and the associated tax hikes that will occur in areas that provide more un-insured healthcare per capita.

As a secondary solution; if you live in a city or near a city with a military hospital and you're uninsured you have to go to these government run facilities. The hospitals can run at a loss and still stay open. there doesn't need to be a profit margin because the workers in these hospitals aren't paid out of any health care based funds. The funds come from the DOD and they pay a brand new soldier much less to do the same job a civilian would do. There's even a possibility to expand the government run facilities and allow them to become specialized care centers. This could also entice the military to expand the education of some of these soldiers.

I can't make a decision to eliminate medicaid because of the fact that people have already put in a lifetime's worth of money before they receive benefits.

Step 4. Larger reimbursements.

With the federal savings from the elimination of JCHAO and other government oversight committees we can afford to offer full compensation for the few uninsured that do make it to local and rural hospitals.

With these larger reimbursements and lowered operating costs that would come from being able to get rid of thousands of middle management jobs whose sole purpose is to ready hospitals for JCAHO inspections hospitals can afford to offer services at lower costs.

5. Have a plan to recoup some of the money that is owed by the uninsured.

The easiest way to do this would be to take money out of any potential tax refund that the unisured may receive at the end of the year. I realize that it does nothing to help with illegal aliens/unemployed abusing the health system. However, if hospitals are given the opportunity to reject care to known abusers of the system these patients can be sent to federal/military hospitals once there, I'm sure something could be done about them being here illegally. If they reject care at one of these facilities our objective is still met. Keeping abusers of the system out of the system. I know the government has the ability to do this, when I got out of the Army I had a military credit card that had a balance of $2.03 that I thought was paid off. The year after I got out of the Army and filed my tax return I got a letter saying these funds would be taken out of my tax return before i would receive a refund. If they can keep track of $2.03 surely they can keep track of thousands that they're owed for health care.

My whole plan is based on trying to eliminate costs that hospitals have to eat, and pass along to patients. If we can lower the actual cost of healthcare services, insurance becomes more affordable/accessible to everyone. This potentially takes many borderline people out of the federal health system. The people I'm talking about are the ones that are close to being able to afford insurance but just can't seem to make the numbers crunch, The people that need help for a short period but are proud, and don't want to be on a free ticket for very long.

If we can start making federal/military/VA hospitals into facilities that can handle these uninsured patients the quality of care in these facilities may go up. If they don't, it may motivate people to find a way to afford insurance. The government isn't going to put up with people using the ER for a cough x2 days. Another benefit could be making some of these hospitals into specialty hospitals that could deal with chronic disease for patients that can't get insurance because of negative health histories. These "specialty" hospitals could also produce more qualified soldiers and soldiers with real specialties that can be more of a help in the work force once they decide to leave the military. The addition of a quality work-force with usable skills that have no student loans could benefit private health systems across the nation in numerous ways.

Tuesday, October 14, 2008

Should you trust your pediatrician?

I was over at Whitecoat Rants and was reading his post about pediatric cold medicines that spilled over into a post about the over-prescription of antibiotics. This reminded me of an older post of mine entitled updates skip down to point number three and it'll help explain where this post is coming from. You really need to read it to understand the rest of my post.

A yeast infection is one thing. Killing a kid with lack of knowledge is entirely different. I'll admit I've tended to blindly follow doctors orders, assuming they knew more than I did, but that all changed about a month and a half ago.

We had a known 11 yr old leukemic patient visit our ER a month or so ago. The kid had a super low platlet count. I think it was 5000 or so. He also had a slightly decreased hgb and hematocrit.

The Er Dr. contacted one of the patients specialists in a larger city about 3 hours away and called me to order an obscene amount of blood and platlet products. I called the E.R. doc and he admitted it sounded like alot but the patient was being admitted so he didn't want to deal with it. Fair enough.

I waited untill the child made it to the floor and asked the nurse to verify exactly what the orders were. I don't know if there was a mix-up in communication or if people just follow whatever protocol they make up, but, she read to me that the Dr. ordered 15 ml/kg of both PRBC and platlets. the kid weighed 50 kg. His hemoglobin was 10. Frankly I couldn't figure out why they were transfusing PRBC in the first place but 750 of PRBC is alot for a 50 kg kid. They also ordered the equvilent of 4 plateletpheresis, which is an ungodly amount. Because of the highly concentrated nature of a platletpheresis product normal protocol is to infuse one unit and perform a platlet count. a more acceptable transfusion ratio is about 5 ml per kg. this ratio should raise the platlet count by about 50,000.

The goal in these scenarios is really just to get the patients platelet count about the spontaneous bleeding threshold of 20,000. The goal isn't to reach "normal" levels again.

I realize I've given entirely too much backstory. So I ask the nurse to please have The Dr. call me to hash out exactly what this kid needed. The Dr. that calls me back is my son's pediatrician. I thought pretty highly of her so I was sure this would be smooth sailing. Not so much. It took me an hour to convince her that giving that much volume to this kid would certainly produce Circulatory overload . I had to fax her an entire chapter in the AABB technical manual to help her make an informed decision.

I'll admit a 50 kg 11 year old with leukemia is a tricky situation not knowing wheter to follow pediatric or adult guidlines considering his weight.

I think I was most troubled by the fact that while I was talking with the Dr. she seemed to sway back and forth and really have no idea what I was talking about. I tried explaining the differences in plateletpheresis and random donor platelets, And I tried explaining that 750 ml of prbc would spike a normal adults HGB about three grams and it would function differently in a 50 kg child.

I understand that as a DR. you can't know everything but It just seemed like this Dr. should have known transfusion protocol for children if she's a peditrician, especially one with leukemic patients.

I just swithced to her because of the whole antibiotic mess, I didn't think she was an idiot, and I hope she's not. I just wonder how much I trust my child's Dr. right now. Pediatricians want to take cold medicines off the shelf because they think parents are too stupid to properly dose their child. In the last year I've had two differnet Dr's make equally stupid decisions. Who can you trust if you can't trust you're child's Dr?

Monday, October 13, 2008

Getting what you earn.

*Disclaimer* This is not unbiased. I have a candidate of choice. Not my first choice, but in this instance definitely the lesser of two evils.

I've been doing alot of research on the health plans that both Sen. McCain and Obama are setting forth.

From What I can understand, the biggest difference is this;

1. Senator Obama supports a system that would provide more government funding/control.

2. Senator Mccain supports a system that is privately run.

My issues/objections to each plan

The U.S. is not a socialist state. It's not the responsiblilty of the federal government to ensure everyone has insurance. It's the responsibility of every individual. At some point and time Americans have lost the attitude that made this nation great. Independece and self-reliance are no long valued. Everyone has their hand out waiting to see what will be given to them.

Sen. Obama's plan to fund another 17 million health care recipients comes from the tax cuts from the bush administration that are set to expire. Many of these tax cuts are for buissness and the wealthy (making over 200,000 per year). So naturally it's okay to take even more from the most heavily taxed bracket, right? to provide for lower income families. This seems like a socialist idea to me. I hardly think it's fair that many lower income families get more out of the system at tax refund time then they put into the system while people in higher tax brackets pay the majority of income tax in america. (I'm not in a higher tax bracket if everyone paid a flat tax percentage that I support I'd actually pay more taxes. But I guess I'm the only one that realizes we all owe our part, and that it's a privledge to live in the U.S.)

Don't get me wrong, I fully support windfall taxes on large companies but I don't think it's fair to overly burden families that have worked hard to do well for themselves. Generating more revenue from this higher bracket with the sole intention of providing (probably sub-standard) care for the poor is not okay.

The obama plan is one step closer to a universal government run health plan that will not be good for patients or health care workers.

The press has gone to great lengths to make people aware of the fact that Sen. Mccain plans to tax health benefits for the first time. He'll then provide a 2,500 or 5,000 tax credit to offset costs. Sen. Biden says the average cost of health insurance in america is about $12,000 per person. I don't know if this is true, personally mine cost about 2,400 for a family of three for just our premiums. I understand that I work for a hospital and I work in a smaller city so my costs will be lower than average. I'm just not sure if 12,000 a year for premiums is a correct estimate.

The government has done similar thing with our income tax for years, allowing you to claim only yourself then at the end of the year claim you deductions hoping for either a refund or a smaller tax bill. They use the money that they collect throughout the year for the operating budget and for investments. Generally these investments have panned out and the government can afford to give some people more than they've put into a system. I don't see the huge problem with the plan to generate extra cash flow without a net increase in taxes for most people.

I don't think universal health care is the answer and I don't think Giving a tax credit on a new tax make a whole lot of sense either. But given the lesser of two evils I pick Senator McCain's Health plan. It puts fewer people on government funded heatlth care and it may give the government a little more flexible cash rather than going with plan A as of late and just printing more money.

I think the answer lies in maintaining privatized insurance with better oversight. The difficult part about this is that I couldn't begin to explain what proper oversight would be. I'm not talking about jchao oversight because those fools have simply made providing good health care more difficult.

I may think I have the answer but I'm probably wrong. I was all for deregulating wall street. Let a free market society work. I can't count how many times I kept telling myself it would all work out, and it will but it'll take some governmental help and oversight which in the past I was all about preventing. I believe in capitalism but every system has it's flaws.

I hope we find a good system for our healtcare. Progress is stimulated by competition and in order to have adequate competetion I believe that the system needs to remain as privatized as possible. Unless everyone out there believes medicare and medicaid have been shining examples of how to run healthcare in America. At some point and time we all need to take responsibility for ourselves and understand that you really do get what you pay for and that we're not entitled to anything free healthcare isn't a right.

My hospital already has policies in place to help offset costs associated with uninsured/medicaid patients. We basically do everything we can within a working diagnosis that we're sure medicaid will pay for. patients will get all kinds of silly workups just in hopes that the volume of tests on a patient will somehow even out the cost, considering how much less medicaid will pay for services.

If I need to explain to you why these are negative things, and how government has screwed up health care I think you should just go vote for Obama's plan that's a step too close to universal healthcare for me.