Wednesday, February 06, 2008

Backed Up For A Few Days

First chance I've had to write in a while. Every time I've sat down to post anything lately there have been interruptions. Here it is, almost 7:00AM on a day off and I finally have some time to ruminate electronically. If I'm rambling during this, it is purely due to being a little bit sleepy. And I apologize in advance.

One of the other things I wanted to write about was the horrible surprise ending to the Super Bowl. I think we all wanted to believe that the New England Patriots would pull it off at the end, especially when the defense had Eli Manning in its clutches but then lost their grip on him. Once he completed that pass, however, the end was in sight.

The ugly truth is that the New York Giants wanted it more. And they outplayed the Pats. It's that simple.

Since the publication of my employer's problems with Medicare and Medicaid billing, there have been efforts to "dam the spillage", for lack of a better way to describe the activity that has taken place within our organization. Every run report that has been written has been audited, not to ensure that patient care activity was documented properly, but to verify that all of the billing information is correct. Also, every employee is required to attend a mandatory compliance class. We have to be educated about the "Corporate Integrity Agreement" we've been placed under with the U.S. Government. It is amazing the number of companies that are under this type of agreement; part of the problem is that the regulations concerning Medicare and Medicaid (especially Medicare) are like the shifting desert sands: they change regularly and the only way to keep up with them is to have someone who works full-time to do that. We sort of do, but it's difficult for him because he has other responsibilities as well.

Anyway, my position on this whole situation hasn't changed much. I'm still really disappointed that the employee base, as a whole, wasn't notified of what had happened by our management; we had to find out about the issue through the print media. That, as far as I'm concerned, was 100% wrong. To have not told those of us who work on the street why we weren't told before the public was given the opportunity to read about it is totally unconscionable. However, I realized that I can't place blame totally on our management; the NH Attorney General's office has to bear some responsibility as it was they who made it possible for the story to be published in the first place. It is too bad that something could not have been worked out between the AG and RRA prior to its publication. However, being the line medic that I am, I have no way of affecting anything that happens at that level. In a manner of speaking, "I don't know nothin'. I just woik here."

I guess the question, at least for me, becomes one of whether or not this has affected whether or not I want to continue to be employed there. At the moment, the answer is not clear to me; I have to give it some serious thought. Basically, one of the things I have to consider is whether or not I go to that proverbial devil that I don't know, or do I stay with the one I do and continue to deal with the things that are going on. And this is a hard thing, because for the most part I like where I work and I really like the people I work with; I've never been part of a crew that is as much of a dysfunctional but caring group as this, and because of this changing work venues is a difficult thing to consider. So for now I will do just that: consider it.

Had a call on Monday that was really noteworthy to talk about for no other reason than its clinical significance. A 38 year-old male, unconscious and unresponsive to verbal or painful stimuli. Breathing on his own at a rate of 24-28/minute but with snoring respirations and really noisy breath sounds - not coarse crackles, but more of a friction rub or rhonchi-type sound. Dried blood on his face around his mouth and nose from an apparent laceration to his tongue from biting it. Bystanders report that he'd been drinking the night before and was last seen at approximately 2:30 AM, extremely impaired.

Firefighters on scene had secured his airway prior to our arriving on scene with a nasophrangeal adjunct and had him on high-flow oxygen. First thing we did was get a quick CBG, which was 15 mg/dl. Very low, indeed.... A couple of the bystanders who were there had some familiarity with his history: no known diabetes but a hard-core alcoholic with a history of liver cirrhosis and positive for Hepatitis C. No known drug use, unknown allergies, unknown if he takes prescription medications with no evidence of meds in his room.

Established an IV and gave him 1 Amp of D50. No change in his mental status. Pupils were not pinpoint, however given his mental status it was prudent to rule out opiates, so we gave him 1 mg of IM Narcan. Still no change in his mental status. Re-check of his blood glucose showed it to be at 128 mg/dl. At that point we got him out of there on a back board and loaded him on the ambulance for transport. We continued the O2, put him on the cardiac monitor - sinus tachychardia at about 120/minute with a systolic blood pressure of 110 - and at that point he started to seize. He got 5 mg of IV Valium, which slowed the seizure activity down substantially, but he was still not mentating appropriately after that. We did rapid transport to CMC, all the while maintaining his airway and doing everything necessary to keep him from being injured.

On arrival at that hospital we got him into the trauma room - the attending doc who I reported to, Dr. W, is one of the crustier characters on staff there - and filled them in on what we had. We moved him onto their stretcher, which was when we discovered that he'd lost bladder and bowel control. What a mess; the decontamination after that was pretty extensive.... They re-checked his BG level, which was down to 66 from 128 less than 10 minutes previously. So they gave him another Amp of D50, and they knocked him down with diprivan (otherwise known as "the milk of amnesia" because of its lipid content and amnesiac properties) and the doc attempted to intubate him with no luck. He had gotten a healthy dose of diprivan, and on top of that he got Etomidate and Succinycholine, which should have stopped everything except his heart. All it succeeded to do, from what I saw, was make it more difficult for him to be intubated. Ultimately, though, they got it done, but it took a while and a lot of drugs to do it.

He went to CT for a head scan, and I had heard from one of the other docs that I know - my friend Dr. S, in fact - that he had suffered a head bleed with some shifting. He didn't have labs back yet, so he couldn't tell me one thing that I was most interested in, which was the level of ammonia in his blood. I'm going to have to follow up tomorrow and see what his outcome was, as I still don't have the whole story. But I have to suspect that his liver went into total failure and because of the alcohol having trashed his vascular tissue his bleed was caused by that action. But we'll see, and I'll try to remember to post what I find out.

Also had a 12 month-old male earlier in the day who was having an allergic reaction. His mother had told us that the pediatrician gave her the go-ahead to increase whole milk from half-and-half (with formula) to just milk, and she'd started him on it that day. He had loose stools not long afterward, and started to exhibit hives a bit later on in the morning. One of the other things that happened prior, however, was that he'd accidentally gotten some Desitin ointment on his finger which he then put in his mouth, and the mom thought maybe this contributed to the reaction. As we had no way of knowing what the trigger was, we did what was necessary to treat him. He was covered from head to toe with hives, but his lungs were clear and he was not having any respiratory distress. Vital signs were all good, and he was acting age-appropriate, which is always a good thing. On top of that, he was really a really handsome kid... Anyway, he didn't like me afterward because I was the mean old man that stuck him in the leg with 10 mg of IM Benadryl to treat the hives. After he was done screaming at the indignation and pain of being poked in the butt cheek, he settled down and started to look around the truck. It was like he was saying to himself, "even though he's a mean old man, he's got some pretty cool toys." So we got him to the Elliot and turned care over to the nursing staff. They proceeded to do many of the same things I did on the ambulance, and I could hear the kid crying and screaming from 4 rooms away. I felt bad for him.... But his outcome was good. I checked on him before we left and he was doing much better.

Well - now that I've exhausted myself enough for one morning.... Time for bed.

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