Medical News

One thing that I hear all of the time from patients and even fellow heath care workers is how the US health care system is broken because it is expensive, yet my fellow workers all say that we are underpaid for what we do.

Medical care is a finite resource. Therefore, you cannot give everyone all of the care that they desire or need. There has to be a way to ration care. In the US, we do that through cost. If you want more or better care, you pay more for it. In many other countries, the oes with so-called “free care,” they ration it by allowing government officials to decide who gets care when. That’s how a woman in the UK with a mass on her ovaries is forced to wait 9 months to have it removed, only to discover that it has become cancerous, which results in a complete hysterectomy and a long course of chemotherapy.

Heath care isn’t cheap, especially when you demand that the people performing it have to be flawless in its execution. Everyone involved in the delivery of care from the janitor, to the nurse, the technicians, and the doctor have to have high levels of training. That raises costs. Starting nurses are making $75k a year in my area, and yet there is still a shortage. With 5 or more years’ experience, nurses in certain specialties are making more than $100k. Florida has pushed a lot of people to go to nursing school and even subsidized people in attending school, yet all this has accomplished is to increase the failure rate of the nursing exam.

Pay is set by market forces- employers pay for good employees. When demand is higher than supply, market forces cause a bidding war for the product- in this case, nurses and other highly skilled workers, which causes pay to rise. We are seeing that here in Florida, and have been since COVID. Nurse pay is rapidly increasing. My employer recently announced a 20% increase in shift differentials and a 5% raise in base pay for nurses.

Your only other choices are:

• Lower standards. This will allow you to pay less, and also allow the hiring of more workers, albeit at a lower skill level. The cost is more accidents and medical mistakes.
• Ration care through waiting lists. This is the path that many nations like Canada and the UK have followed. The cost here is people dying while on the waiting list.

There is no such thing as a free lunch. There is a bill to be paid, the only question is how it will be paid. No matter what, someone is going to pay these workers. The patient can pay for healthcare at the point of sale, or everyone can pay for it when it is deducted from your paycheck, but we are going to pay for it regardless.

I have done previous posts on firefighting, brain injuries, and other things seen in my various lines of work. Response to these insights into how the sausage is made have been generally positive, so I figured I would toss out another one.

Ever since Florida legalized medical marijuana, those of us who work in the emergency department have seen an alarming uptick in people coming in with complaints of nonstop vomiting. If you ask, they will usually admit to you that they smoke marijuana. Those who won’t admit it always show it on toxicology screens.

The syndrome that is responsible for this is Cannabinoid Hyperemesis Syndrome, or CHS. This is a fairly new thing that has been becoming more and more of a thing since the legalization of marijuana has gained steam across the country.

How is it spotted?

It is reported in people who are frequent (more than once per week) users of cannabis for a year or more. The signs are pretty easy to spot:

• The victims make a loud, very characteristic retching sound
• Vomiting as often as 6 to 10 times per hour
• History of frequent marijuana use within the past 24 hours and over the past year or more
• Symptoms do not respond well to standard antiemetics (Zofran, Reglan, Compazine)
• The person will seek out and even crave hot baths and showers for temporary relief, but as soon as the shower is over, the vomiting starts back up again
• The symptoms ARE well controlled with psychoactive medications like Haldol
• They will also admit that they have been having lower abdominal pain/cramps for weeks before they began vomiting.

CHS is often misdiagnosed as Cyclic Vomiting Syndrome, but note that CHS patients when questioned will tell you that they seek out hot water baths and/or showers for temporary relief of symptoms. CVS patients don’t get relief from hot bathing and showering.

Whenever I get a patient who complains of frequent bouts of vomiting, I always administer 8mg of Zofran (I have standing orders that I can give that to anyone over the age of 16 without asking the doctor) and order a urine drug screen. If the Zofran doesn’t work, I can be fairly sure that CHS is what we are looking at.

Then I ask them what they do to relieve their symptoms. They will always tell you that while they are in a hot bath or shower, they stop vomiting. Once we know for sure that they are cannabis users, I ask the doctor for an order for Haldol. I usually get it.

At the same time, we need to make sure that the frequent vomiting hasn’t been causing any mischief , so we will also do a CBC, a Comprehensive Metabolic Panel, and will also give them a liter of normal saline and possibly 2 grams of Magnesium sulfate. Expect to see elevated WBC counts in patients who have been vomiting for a while. Absent other signs of infection, this is an inflammatory response to the vomiting.

Depending on other factors found in the initial assessment, an abdominal CT with contrast, or even a head CT without contrast will also be ordered.

Prevalance

Since people are frequently dishonest about marijuana use, its impossible to know for sure, but among people who DO admit to frequent use of cannabis, between 35 and 45 percent report frequent vomiting. This is in line with my personal experience- nearly two thirds of those who come in with vomiting complaints test positive for weed, as opposed to about ten percent of general teen and adult patients.

No one is exactly sure what causes CHS. It is believed that, although cannabis calms the vomiting center in the hypothalamus, it also irritates the enteric nervous system. That theory also explains why hot bathing seems to give temporary relief, as the hypothalamus also controls body temperature.

The patients that I talk to admit to anything from “just one joint at night before I go to bed to help me sleep” all the way to “all day, every day. As many as 15 joints per day.” With edibles, I have had people say that they eat as many as 6 to 10 edible gummies per day. That’s a lot of weed.

Treatment

To stop them from vomiting, the administration of 5 mg of Haldol usually does the trick and will stop the vomiting for a few hours. Antiemetics, including Zofran and Reglan don’t work very well or at all. Even with Haldol, the next time they use, the vomiting will start right back up again. The only way to stop the vomiting on a permanent basis is for them to stop using cannabis. Within a day or two, the vomiting will stop.

The problem is that people who use marijuana don’t believe you and will continue to do so. You will see them again in a week or two. Rinse, repeat. There is also a myth that you can’t overdose on weed. We are finding out that this is not true. The more weed, the higher your odds of seeing me with your CHS. Left untreated, constant vomiting can be fatal by causing lethal electrolyte imbalances. The severe retching that comes with it can cause issues like a Mallory-Weiss tear.

*I have also heard that rubbing capsaicin cream on the abdomen provides the same temporary relief as hot showers, but I have no personal data or experience on that. I would assume that long term use of this method will become less and less effective over time.

I just did something for the first time in my 35 years as a healthcare worker- I refused to accept a patient. When I got to work, the nurses in one zone were keeping a ratio of 4 to 1. My assignment was to take 3 patients from 3 different nurses, which together with the other nurses arriving at the same time as I would be lowering the zone to a 3 to 1 ratio.

Two of the nurses turned over their patients with no issues. The third nurse was Nurse Slacker, so I took a look at the chart. The patient had been placed in that room an hour and a half earlier, and nothing had been done. No vital signs had been taken, no IV started, no lab work ordered or drawn, and no assessment had been done. I went to the charge nurse and told him that I would not be accepting responsibility for that patient until the nurse actually did her job.

 I will not be placing my name anywhere on that nurse’s chart and refuse to accept her patients unless they are properly cared for and it is properly documented. I am not risking my medical license for that incompetent, lazy slacker of a nurse. You can’t make me assume care for someone else’s patients when that person hasn’t done a single thing for them. The rest of the nurses in the zone won’t assist her because they aren’t willing to do her job for her, either.

When she finally came to me to give me report two hours later, she hadn’t even noticed that the charge nurse had done everything, treated the patient, and discharged her an hour earlier. That’s right, her patient had been gone for an hour and she never even noticed.

The charge nurse had no problem with it, and said that it would help if she wasn’t off the floor half the time. Management needs to do something, but they won’t.

EDITED TO ADD

For those who are asking: She is white. However, she is in a protected class, that of breastfeeding mothers. It’s due to a Federal law called the Providing Urgent Maternal Protections for Nursing Mothers Act (PUMP Act). The law says that employees who are nursing have the right to reasonable break time and a place, other than a bathroom, that is shielded from view to express breast milk while at work. Sure, it says reasonable, but that is subject to a court’s interpretation. What this means is exactly what the woman has told fellow employees- she can be in the pumping lounge as often and for as long as SHE thinks is reasonable. On of our charge nurses told me that they had a meeting about her, and they have been told that she is untouchable because she has already been to HR with her attorney in tow.

This woman here had a child that was born prematurely. That child spent a month in the Neonatal Intensive Care Unit (NICU). The bill came to $738,360, and the mother complains that the cost is too high. There are many in the comments that agree, and it’s filled with comments about how other countries have free healthcare, which is of course false.

The bill for that child’s care is completely reasonable. Let me explain why:

Nurses work 3, 12 hour shifts per week, and NICU nurses are frequently on 1:1 care, meaning one nurse to one patient. A 30 day stay in the NICU means that your child had the undivided attention of 5 nurses for a month. An experienced nurse, (for obvious reasons NICU nurses tend to be fairly experienced, qualified, competent, and educated) aren’t cheap. The average pay for a NICU nurse in the US is about $130,000 a year. Night shift makes even more, thanks to shift differentials.

The nurses in charge of your child’s care cost the hospital $70,000 in direct compensation, plus the costs of insurance, training, and other HR expenses. In all, just the nursing care for that month in the hospital cost that hospital about $140,000. Now add in the costs of everyone involved in that from the doctors to the lab technicians, and even the janitors.

Each of those people is highly educated, even the janitor. Yes, the janitor. To comply with Federal law, that janitor has to be instructed on CPR, stroke procedures, HIPAA compliance, Medicare and Medicaid laws, sex trafficking, recognizing child abuse, disposing of medical waste, and a host of other laws. He also needs to be background and possibly drug checked, especially to work in a pediatric wing. All of this raises the cost of hiring that janitor.

Back to the nurses. It takes 3 years of schooling to become a registered nurse. Then it takes years of experience, training, and work to specialize as a NICU nurse. In all, the average NICU nurse has been a nurse for 5 years or more and has attended far more schooling than a beginning nurse. Pediatrics is a specialty. So is neonatology, as is critical care. NICU nurses have to certify as all three. That’s why they make what they make- competence costs money.

Then there is the lab work, the cost of provider that supervises those NICU nurses (usually a nurse practitioner), lab technicians, respiratory therapists, medications, medical equipment, supplies, meals, and even the guy that empties the trash. Then there are the doctors, as well as the regulatory costs of compliance.

In total, labor costs alone for that stay were probably in the neighborhood of $300,000, so I don’t think $700k is out of line once you do the math.

That isn’t even considering what procedures may have been done- if surgery was involved, you can also add anesthesia, scrub nurses, surgical nurses, and a host of other specialties and specialized equipment.

The argument that other countries offer free healthcare is false. The care isn’t free, it is paid for through taxes. Even then, there aren’t enough professionals to go around, so care is rationed, and even Canada offers to kill the patient, putting them down like a race horse with a broken leg once the cost of their care gets too expensive.

There are ways to make this sort of care cheaper, but every one of those ways involves compromising the level of care. You can increase the nurse to patient ratio, but this means that the patient is left to fend for themselves for longer periods of time. You can get away with that for an adult admitted with a broken hip, but not for an infant that is near death.

Americans demand perfect healthcare, but then complain when the bill comes due. You want good care, and you want it now? Then it won’t be cheap.

Everyone likes to complain that healthcare costs too much, and then complains about the “healthcare system” as if it is some sort of unified national entity that is controlled from the top. It isn’t. What we call healthcare in this country is a marketplace made up of hundreds of thousands of companies, each reacting on an individual basis to market conditions.

The largest of these changing conditions is CMS, the Centers for Medicare and Medicaid Services. They set the conditions under which they will pay for medical services. For example, if a person comes into the hospital with signs of sepsis, that person must receive a blood test for lactic acid levels. If that level is greater than two, the person must be tested again within 6 hours, or the hospital doesn’t get paid. This is repeated all over the entire field of payments from CMS. They regulate everything.

They tell hospitals what procedures must be done, how they will be done, and what each provider can charge for all of those procedures and tests. They also dictate that CMS has to be charged the same amount as every other patient. With CMS directly controlling 32% of all healthcare spending in the US, and indirectly controlling another 40% of medical spending by dictating policies to insurance companies, they are the 800 pound gorilla in the room.

If a provider doesn’t play ball, they don’t get paid, and can be added to the national list of “CMS doesn’t let this person be involved in medical payments” blacklist that effectively ruins your career by making sure that 72% of patients can’t use insurance, Medicare, or Medicaid to pay for your services. No one will hire you. It’s even a question on hospital job applications- “Are you on the CMS naughty list?”

So the market responds to that by doing what they are told to do by the Feds.

Then there are the patients themselves. I can’t tell you the number of times that a patient comes into the hospital every day with COPD but is still smoking. There are the diabetics who come in complaining of numbness in their feet, blurry vision, and stomach pain with a blood glucose level over 500 and an A1C of 12, but will lie and tell you that they are watching their diet and taking their medication. There are the drug addicts who come in twice a week because they overdosed, and the drug seekers who come in nearly every day looking for a pain med fix. (We have one woman who has already been in the ED 14 times this month, and it’s only 17 days into December.) The person having a stroke who has a history of high blood pressure, but doesn’t take their medication. Yes, each of these were patients I saw during the last week, and each of them blamed doctors for not fixing their problems in an hour or less, even though their problems were entirely self created.

There is an endless parade of patients who come in with cannabinoid hyperemesis syndrome who won’t stop smoking weed, or STIs because they won’t stop mating with every person who will take their clothes off, Mental health patients, homeless who want free sandwiches, and illegal immigrants who use us as their primary care.

All of these people get seen under a law called EMTALA, which mandates that hospitals have them evaluated whether or not they can pay. Once they are evaluated, those CMS rules we talked about earlier dictate that they have to be treated. Then the entire thing gets paid for by your taxes.

Then after all of that, people then sue the practitioners, workers, hospitals, and drug makers who followed all of those rules and win millions of dollars in payouts.

The problem isn’t healthcare- we as a nation have the best healthcare in the world. What is screwing things up is market manipulation by the government. Imagine for a moment that the Feds were doing the same with the “restaurant system.” That is, 72% of all food was paid for by the government, who set standards on what everyone could eat, how much they could eat, how that food must be prepared, and under what conditions grocery stores and restaurants would be paid. Then they also dictated that anyone who went to a restaurant that had a drive through would have to be served whether or not they could pay for it, but then reimbursed the restaurant for the meal cost. All of this regulated to the point that there are hundreds of thousands of rules, each of which must be followed to the letter. What would a restaurant look like, and how much would a meal cost?

I don’t think most people have a problem with the care they are getting, and those who do frequently misunderstand why they got what care they did get. Most people are upset at the cost, and that cost is directly related to the government distorting the market, and the market’s entirely rational response to that manipulation.

What makes me laugh the most is that everyone then blames the doctors and other facilities, then demands that the government step in to fix the problems that the government created. That’s true whether you want more regulation, single payer, or some other government intervention.

Mammals, or humans in particular as it relates to this post, need to exchange gases. We take in oxygen and get rid of carbon dioxide. The process that we use to do that is breathing. There are two components to that process: ventilation, and respiration.

Ventilation is the mechanical process of moving air (or other gases) into and out of the lungs. Ventilation requires a functioning respiratory drive (provided by the CNS and portions of the PNS), an intact and functioning chest wall, the airways, and lung tissue that is functioning properly. Being a mechanical process, there are things that can affect it: physical blockages of the airway through trauma, inflammation, or even a failure to maintain open air passages because of dysfunction in the nervous system.

Respiration is the actual exchange of gases, first across the alveolar membranes, then into the blood, into the tissues of the body, then back to the blood and across the alveolar membranes to be expelled from the body. This process depends upon the relative pressures of the gases involved. Things like partial pressure, electrochemical gradient, pH, and other factors play a huge role in the moving of gases into and out of the lungs.

Entire textbooks are written on how this process works, so this limited post won’t be an exhaustive treatise on the function of the respiratory system. I want to mention mechanical ventilation and why intubating a patient and placing them on a ventilator is so important.

There are times when a patient’s respiration doesn’t function as it should. Perhaps the process of gas exchange has been disrupted because another gas has more affinity for the chemical reactions that are taking place, as is the case with hemoglobin’s stronger affinity for carbon monoxide than oxygen. Maybe the pH of the blood is shifting, causing gas exchange in the alveoli to cease. There are a lot of reasons why this can stop working as it should, and these can be addressed through multiple means. The simplest of these is simply putting a nasal cannula in place to deliver oxygen at a slightly higher partial pressure. Still, there are times when these tricks don’t work and respiration breaks down.

Once the breakdown in the processes of ventilation and respiration take place, a person will begin to struggle to breathe. The work of breathing increases, and the patient has to put in more and more effort to get a breath. This is extremely tiring. Sooner or later, the person becomes too exhausted to breathe, and slips into what is called respiratory failure. When this sets in, there are again numerous things that can be done to assist the person in breathing. BiPAP and CPAP are two ways to do this. However, if these measures don’t work, or if the person can’t breathe on their own, then someone or something has to breathe for them.

In the short term, a device called a bag valve mask allows medical personnel to breathe for the patient, but this isn’t a long term solution, nor is it very useful for delivering higher levels of pressure to the gases involved.

Ultimately, a person who is not breathing well on their own will wind up with a tube down their throat and a machine called a ventilator doing their breathing for them. This can be done because the person can’t keep their airways open when they are unconscious, like during surgery. It can be done because they have significant damage to the nervous system, for example a broken neck has damaged their phrenic nerve, are simply too tired to breathe, like during an asthma attack, and for a host of other reasons.

Here is a recent, real-life example. Steve is a known IV drug user who was found in his backyard by EMS. He is breathing with grunting, low volume respirations that are clearly ineffective. EMS tried giving him Narcan, but it had no effect, so they began ventilating him with a bag valve mask. Since he still had a gag reflex, they were unable to intubate the patient.

The doctor in the emergency room decides that he needs to be intubated and placed on a ventilator because he is simply incapable of maintaining and protecting his own airway. The staff gives him etomidate to sedate him, rocuronium to paralyze him, then the doctor inserts the tube before a respiratory therapist places him on a ventilator. The process is fast, taking less than 5 minutes.

The drugs used to place the tube will wear off in just a few minutes, so the patient needs to be sedated to keep him from fighting against the ventilator. Drugs like Versed, Propofol, Ketamine, and Fentanyl are used to keep the patient sedated. Of course, those drugs cause side effects that must also be dealt with. It becomes a delicate process of keep the patient sedated to the correct level while also maintaining the other parameters, as well as dealing with the drug overdose and the issues that it caused.

In the above case, the patient had rhabdomyolysis, liver failure, kidney failure, and a host of other issues that had to be dealt with. Dealing with those issues takes time, but unless a patient is breathing, time is what you don’t have. Ventilation buys you that time to deal with it.

There are COVID (as well as influenza and pneumonia) who get intubated to this day. Some make it, some do not. It’s not the ventilation that kills those patients, it’s the sepsis and the immune system’s response to it that kills them. In some patients’ cases, ventilation does more harm than good, but overall, mechanical ventilation is a process that saves thousands of lives per year.