PSOTBLOG

Sedation Analgesia Test

In 1983 I was honored to be named the editor of the AAFP textbook on Flexible Sigmoidoscopy and Colonoscopy. Among all the books written on the subject, I was the only one to include the techniques of sedation/analgesia. Special thanks to all the family physician pioneers who accepted the challenge of writing  and teaching. For twenty years my faculty group held the high ground and shamelessly used the annual scientific assembly as a faculty development session while simultaneously providiing political support for the many family physicians who were summarily refused privileges to perform this life saving procedure.
 
As family physicians could not easily obtain hospital privilges they were forced to buy and maintain equipment within their own offices. In regions where reimbursement was linked to hospital privileges, colonoscopy in family medicine withered. The AAFP did not successfully defend these issues, and the course demand predictably decreased. The course was downsized and reconstituted under the able leadership of Drs. Pope, Forman, Coleman, and others. But the AAFP scientific assemblly ceased to be a revival meeting for procedural faculty.
 
My last revision of the colonoscopy book was published in 2004, which was the year I stopped teaching the course. The AAFP took my book and published it, but never sent me a copy for proofreading. Since we had taught over 2,000 physicians from the book for over twenty years. the four revisions seemed to address most issues of accuracy.
 
But the final edition was changed without review, and the sedation analgesia test was inaccurate through the process of retyping and inattention to detail. Since I was no longer involved with the course and knew that others would be doing their own book, I did not revisit the issue. I assumed the book would die a natural death which it has.
 
But, it is clear that the topic of office anesthesia needs to be included in our fellowship curriculum. Attaining procedural excellence during the standard three year FM residency curriculum, seems unlikely. Most of the family medicine residencies are owned by hospital administrators and subspecialty oriented academic medical centers whose interests are not aligned with procedural teaching for family physicians. Therefore, I am proposing that these skills be incorporated into the Medicos' Fellowship curriculum book.
 
Problem based learning uses the multiple choice question as a clinical simulation with the goal of achieving an objective measure of attained skill. CFR 42.12 requires that hospital evaluate physicians by things other than board certification, and these instruments should serve to establish specialty neutral credentialing. I have labeled this process problem based learning and competency based testing.

 Wm. MacMillan Rodney MD, FAAFP, FACEP
Clinical Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural Tn.
www.psot.com

Index--Fellowship curriculum, sedation/ analgesia, moderate sedation, surgery in the office

Should Hysterectomy Training Be Required As Part Of Privileging For Cesarean Section?

Hello esteemed colleagues:

I work in a town of 8700, though our hospital serves an encatchment area of about 25,000. Our community on average has about 100-130 deliveries a year, currently divided amongst 6 family doctors (ie. the numbers are low and therefore difficult to support another FP c-section provider much less an OB/gyn).  2 of us are fellowship trained and therefore skilled to provide operative obstetrics; however, neither of us is skilled to perform hysterectomies.

Just in the past year alone, we have had two hair-raising experiences of placenta accretas that were not diagnosed prior to labor/delivery, which has raised serious questions about appropriate back-up and management of these situations.

Our closest hospitals with full time OB/gyn coverage are an hour away (one to the south and one to the west). Since we do not have control over who presents to our birth center, and transferring pts out is not always possible, I am wondering how you and your communities have handled these c-hyst situations (eg. placenta accreta/increta/percreta, persistent uterine atony).

Very appreciative of any advice or guidance you could provide,

Molly Hong, MD

Molly:

My answer would be the same as Ben Brewer.  I practice in Fort Stockton, Tx.  Shortly after I obtained the experience and therefore privileges for hysterectomy 20 years ago, the situation arose for a C-Hyst.  The patient and I both survived the experience.  It is 85 miles to the nearest OB/Gyn specialist, the general surgeon was out of town, and at the time there was no air transport available.  You can do it.

Cecil George, MD

Molly:

The most direct answer to this is more training on your part and advancing your skills to doing hysterectomies.  You've learned the c-section part.  The hysterectomy portion is not that tough on top of your knowledge base and surgical skills.  The control of bleeding and avoidance of the ureters and the bladder are the key elements.  The question is case volume and confidence/competence level.  At our facility, I would call one of our two general surgeons to help me out in one of these cases even though I've had the training. 

I did about 25 abdominal hysterectomies as the main surgeon in fellowship, but I haven't had to do a hysterectomy in a c-section in 11 years.  With 25-50 hysterectomy cases I think the average fellowship trained FP/OB  would be fine.  Where can you get this training?  Perhaps a community preceptorship or a medical mission working with a general surgeon/OB/FP to show you the techniques. 

My OB fellowship director trained at Duke as chief resident in OB/GYN and he'd done a total of 1 c-Hyst in his training.  This shows these are rare and nasty cases that challenge anyone.  You now have double his experience. 

For Uterine Atony, you can inject Pitocin IM directly into the uterus.  IM Methergine works too, just don't inject it IV.  I've never injected Methergine directly into the uterus. 

For bleeding risk stratification beware the previa and the anterior low lying placenta particularly in the margin of the old uterine scar.  The blood vessels in the area don't clamp down as well.  In rare cases they may need to be oversown circumferentially.

As a general rule if you wait for the placenta to spontaneously detach during your routine cases rather than manually extracting it, you'll lose less blood and the post op hemoglobin will be half a gram higher.

Ben Brewer M.D.
Gibson City, IL 

(The smallest rural hospital in Illinois still doing OB) I also perform cesarean in a town of 6000, 4 docs who do about 180-200 deliveries a year.  We have an obstetrician and a general surgeon who both serve 2 communities.  I perform about 25-40 cesareans a year, and have had to perform an oophorectomy at cesarean and BTL as well as assist with a surgeon for a cesarean hysterectomy in a patient with percreta who was hemorrhaging.

The issue of cesarean hysterectomy is ALWAYS going to be the reason cited by obstetricians for why we should not be doing cesarean.  However, in your community, patients simply have too far to travel.  You ARE providing a valuable service.  The issue is going to be HOW you manage a post op hemorrhage, and less WHO is managing it.

I would get to know your perinatologists at your referral center.  I have a good professional relationship with mine, who are 45 minutes away.  While it is certain they won't openly support a family physician doing cesarean in front of their colleagues, they usually will be congenial to your face.  And if you demonstrate competent management skills, you have an opportunity to positively affect their opinion of our humble specialty.

Familiarize yourself with management techniques for postpartum hemorrhage, including uterine artery ligation, intrauterine balloon, B-lynch, subendometrial vasopressin.  Transfer of the patient is ALWAYS an option.  Even in my community, it is frequent that BOTH the surgeon and obstetrician are gone on vacation or unavailable.

Here are some examples from my experience:

1)  Our obstetrician had a cesarean post partum hemorrhage in a 400lb patient in a smaller outlying hospital just last year.  The hospital had only 4 units of blood, none compatible with the patient, no FFP, no platelets.  He placed an intrauterine balloon and flew her by helicopter to the tertiary care center.  Our obstetrician was on teaching staff in the past at a major medical center.  This is his "retirement" home now.  I value his experience.  He spoke with the accepting physician, a colleague, at a tertiary medical center, WHO KNEW HIS CREDENTIALS.  And he got the usual "Why can't you control it?  and The bleeding can't be that bad...".  After arriving at the center, they spent the next 10 hours trying to stop her bleeding nonsurgically, finally conceeding and doing a hysterectomy.  Our obstetrician got a phone call back the next day from the attending, apologizing.  So it goes to show that the disrespect extends to all rural docs, not just FPs.

2)  In my 3rd year of practice, I opened a patient during a scheduled, elective RLTCS to discover a percreta complete with a uterine "window" in the old c/s scar through which I could see the baby's face.  Mom was awake, stable, and baby in no distress.  I phoned the perinatologist, who was gracious to accept the patient.  We closed the abdominal incision and I rode with her by ambulance to the referral center, where she had a healthy baby later that day.  She lost her uterus and fortunately had no further complication.  That case earned me some respect from the tertiary care center.

3)  You will ALWAYS lose 2-3 years of your life during one of these cases.  You will ALWAYS question why in the he&& you ever chose to perform cesareans.  But you ALWAYS will come out of it a better doctor.  Remember:  "Pain is weakness leaving the body."

Shane Avery MD

We have always had a general surgeon available. but now days they aren't coming out of residency with the training in GYn that they used to have. We've even had to train some of them in C-sections.

John Carroll

I do a lot of repeats, and I didn't do a c.Hyst in 11 years. BUT I DO HAVE CONTROL OF MY PRACTICE AND BACK UP IS NOT A PROBLEM.
I think that By-Pass is not available everywhere, or trauma surgeon, of others. Perhaps best for you Molly will be to set a definite referral/back up system, because most probably you will not encounter a C-Hyst for a very long time.......... and I do not know how useful will be to go for a training. Packing, O'leary, and learn how to put stitches in the main arteries will be enough.

Eduardo Scholcoff, MD
Rockford IL  

One option for rural docs who need to learn some advanced procedures could be to take part in some international rotations such as those I lead for residents now at JPS and before at Brazos Family Medicine.  Many of our international sites are "procedure rich" environments and when we have old missionary docs along for the trip like myself, we can help with some hysterectomy and advanced surgical training for those in your situation. I've done 6 or 7 C-Hysts over the years in difficult situations overseas and knowing how to do a quick hysterectomy has been a life saver
 
John Gibson, MD
JPS
Ft Worth

Index--Family medicine OB Cases; Cesarean hysterectomy; fellowship curriculum

Rosaries In The Waiting Room

 

 

CASE 1.A 47year old Latino male was brought to the office after experiencing an automobile accident with blunt trauma to the chest. Alert, but dyspneic, diaphoretic, pulse of 180, and BP of 80/40, Medicos suspected traumatic aortic aneursym with probable cardiac tamponade. We appreciated the vote of confidence by the family in bringing him to Medicos, but...................................
 
Within ten minutes 911 had responded and the patient was tranported to local trauma center where subsequent details are fuzzy. Medicos was not part of the team there, but an operation ensued and, after 4 days the patient never left the ICU. This was confirmed by a cousin who came to the office today with the following incredible story. They do not speak English.
 
"Yesterday, the doctors in the hospital asked permission to disconnect the ventilator because they said he is "brain dead". But he is moving his hands and we saw "tears". We refused to disconnect the ventilator they said. The family was confused by the doctors' suggestion that they should authorize removal of life support from someone who was "alive."
 
The next day the doctors requested permission harvest his organs. Bad move. The family refused to donate the organs and grew angrier.
 
The next day the family perceived that someone said that the donation of the organs could be used to "pay for the hospital expenses"  Nothing is in writing and I believe that all involved on both sides were victimized by language and cultural barriers. However, this is the same hospital where ER receiving doctors have threatened to "turn you in if you transfer ..."a critically ill patient"(who happens to be uninsured).
 
Originally Medicos' physicians were wondering if they should have acted more quickly to insert a chest tube in the office. I am glad that they did not. Medicos is a lot of things, but blunt trauma aortic injury carries a mortality and disabillty prognosis of over 50% in the best of hands. Nevertheless our young doctors were wondering if they should have more "emergency drills" and/or should be the stocking of chest tubes in the office.
 
What would have happened if Medicos had the chest tube and someone had inserted it? By the way, everything happened in the waiting room. Stocking chest tubes for insertion in the office is not on the "to do" list. This is the third time in nine years we have seen the patients in the waiting room take out their rosaries and start to pray. We call it the "Rosary Sign"
 
CASE #2
    23 yo G3P2 at 20 weeks EGA for routine prenatal vist. Dr decides to use the M-mode on theultrasound as part of the routine check. No charge. Here's what the image shows. Any problem?

In the white box the FHR is 84 bpm. Now that you mention it, the mother states that the baby may have been moving less this week.Fetal movement is noted on today's ultrasound, and there are no no obvious abnormalities. Okey-Dokey. Now what?
 
Case #3
EGA 11 weeks active varicella in 20 yo G2P1. Caught it from her 12 month old child who is at home. The recovered last month and is OK.
Anything to do?
 
Case #4
22 yo WF with hx of "IBS". Office colonosocpy produces this photo. Can you see the IBS lesions?
 

Index--Family Medicine-OB-ER, Rosaries in the waiting room, the risks and benefits of too much equipment
www.medicosmundial.com
Index--High tech, high touch, high acuity cases

Topic: Varicella Postpartum

QUESTION:

Varicella is something we see often in our population, usually the men.  A lot of our patients are not immunized, and have not had varicella as children. Should we be screening our women during their prenatal care?(Comments from the FamDel listserv are included below my reply ed note wmr)

Conchita Martinez MD
 
REPLY (wmr):

Medicos presented the case of a young G2P1 at an EGA of 11 weeks who had visible lesions and a syndrome consistent with chickenpox. Her son had a similar illness a month earlier and he was well. Medicos depends on ultrasound to address the emotional crisis of the mother who senses potential threat to her unborn infant. In our experience this is the most immediately available (and affordable) benefit since all of these ultrasounds are performed by Medicos physicians in the office. IgG titers are not available to our uninsured patients, and has no immediate impact on the management of others.
 
After the first visit, Medicos sees her again in two days to reinforce the viability of the fetus. I would not recommend enrollment into any experimental vaccination programs for this individual patient at this time. In my experience this is a potential promise which has unpredictable results and it creates a need for large amounts of unreimbursed administrative energy. Medicos receives no government support and no charity.
 
Further, promises of enrollment in a super-scientific but experimental program seems to add fuel to the fires of anxiety in the family.
 
Physicians within Medicos have the professional autonomy to override my suggestions (they do it with regularity). But, the patient would have to be referred to a government supported clinic or the university where these experimental protocols are said to be available. In my experience, it is almost impossible to make this system work in any predictable way so this would be an immediate referral.
 
Therefore, if physicians implemented a screening program for women who were already pregnant, is the potential benefit worth the emotional morbidity of the positves which are found? Is there a proven benefit which has been documented in the scientific literature? Our review of information on the topic, indicates that among 40 women in this situation, 91% went on to deliver healthy infants. Nine percent experienced miscarriages. these are case reports and no other outcome based studies were located. Additional information would be appreciated.

wmr

As to seriousness...I was on the team in med school that had to unhook a woman with varicella pneumonia from the respirator, after the OB team had sectioned her to rescue the baby.  Dad got to take his newborn child home and bury his dead wife in the same week.  Varicella in adults can be a VERY serious illness.

Tony Anderson, M.D.
Fort Worth

We have been asking all women at enrollment if they have a history of chickenpox. If not, we then check IgG titers.If unprotected, then we offer vaccine pp.  Until recently, the recommendation was to wait to give this live virus vaccine until the baby was 6 months old (or for mom and baby to get it together at 12 mo), but the latest CDC guidelines now recommend it pp.

We also educate about how important it is to tell us if they are exposed to chickenpox so we can get the now only experimental replacement for VZIG.Ideally, they get the first of the 2 shot series in the hospital before going home and the second at the pp visit. 
 
We have also been trying to give the Tdap in the hospital if it has been more than 2 yrs since their last Td.  If it is overlooked, we offer it at the pp visit.

Kathy Stienstra

Hi:

Hope you don't mind me asking questions (and betraying my likely ignorance). The question posed here suggests something along the lines of "it's really important to immunize varicella-naive adults".

I know varicella in an adult is a potentially more serious infection,but it's also a rare event (so I suppose). So my questions are:

- how important is it to immunize varicella-naive adults? and
- how do you know you have varicella-naive women, which is to say, are  we supposed to be screening all pregnant women?

What is the evidence?

Josh

On Oct 20, 2008, at 9:35 PM, christine pecci wrote:

Wondering if people are giving varicella to those nonimmune to varicella immediate postpartum prior to discharge from the hospital. I have been witholding it just to avoid giving a live virus vaccine in the first few days of life and then put it on the discharge summary in hopes that the PCP will give it at the postpartum visit.  However, as you all know, the compliance with postpartum visits is not good. The Red Book and Hale breastfeeding  book says that the vaccine is not contraindicated with breastfeeding  but I still feel like there is a difference between giving it immed after delivery vs. a little later. 
 
At Boston University we are trying to standardize postpartum care for all women; was wondering what you all are doing in practice.

Incidentally, we are trying to give Tdap immediately postpartum prior to discharge but trying to look through outpt records to see who needs one has been very very time consuming.

Thanks,

Christine Pecci
Director Maternal Child Health
Boston University

What I know about varicella in pregnancy is 13 years old, but I know it well as I had varicella during my first pregnancy. The fetus can become infected and develop a syndrome consisting of short limbs, mental retardation and other neuro deficits. However, the greatest risk is when the mother is in the second trimester when ill. The risk for maternal complications such as varicella pneumonia is much higher than in the non pregnant adult population.
 
Acyclovir can be used to reduce risk of complications, but it is unknown how much risk reduction it offers.
 
An ultrasound later in the second trimester with careful limb measurements might be prudent, but of course, this would only be to inform the mother, not to effect outcome. The good news is that the vast majority of pregnant women and their gestating fetuses do just fine.
 
My N of 1 experience was that I was very ill, took over a month to fully crust over the lesions, but had a healthy full term infant who is now an extremely bright long limbed 13 year old.
 
I would recommend a screen to women who do not recall having varicella in pregnancy and who have not been immunized.
 
Best,

Ruth    

Index--OB varicella

Delivery Billing Question

Question:

I have a question that needs some clarfication regarding a patient below.  The FM team, including myself, managed the patient all day on 9/5, but the patient seemed to be heading to a C/S due to failure to descend and the head never engaged.  EFW done in L&D was over 4200 grams.  OB was consulted and the thought was to perform a C/S, but there was another patient requiring an urgent section.  I went home and had discussed this option with the Doctor; the patient was still 5 cm.  Once they were done with the C/S, I was called by my FM resident and notified that our patient had just pushed out the baby and OB performed the delivery.  This sounds rather precipitous in nature and was wondering who should rightlfully get credit for the delivery as we had invested long exhaustive hours of management.
 
Please, advise.  (I thought I had filled this information into the database and summarized all in the comment section)
 
MDC

Whose faculty name is on the delivery note? Which faculty signed the discharge note?
 
It sounds as though OB did the delivery after a referral for Cesarean. Even though the baby delivered precip(failed Cesarean), the delivery was on the service of OB, and probably they get the revenue.
 
On the other hand, the Family Medicine residents can still receive educational revenue from this delivery. Under current RRC accounting rules, the in-house family medicine resident should get academic credit for the delivery if they were in the room at the time of delivery and/or substantially involved with the labor and delivery management. This educational revenue was a key concept in our "shared call" system, and the meeting of accreditation standards is a major goal for the Meharry-Medicos collaboration
 
If you have seen this weekend's email stream, we are auditing this issue of "fair billing". Medicos seeks the department's counsel on whether this should be discussed at the Wednesday meeting or should we obtain a private meeting with FM-OB faculty?
 
Under a rational billing system, you[the family physician] would still get credit and revenue for insured patients who, after a lengthy labor, are referred to OB for Cesarean. This includes Tenncare.  The family physicians should bill level 3 hospital admission, contraction stress testing, and continuing care time which is about $120 per hour. I assume family medicine did the postpartum care and the discharge(all billable). Tenncare frequently pays about 40% of this, but the billing needs to be prepared in a very specific and timely way. Most university billing systems do not provide this level of billing sophistication, and, at UT, these charges were usually lost.

This is part of the practice management curriculum we should be teaching at these regular conferences. Our common goal is to ethically maximize revenue for the department of family medicine. If the patient was uninsured, this is all academic, but still important to understand.
 

Index--Billing OB

FLU SEASON UPDATE

The first wave of viral illness for the 2008-2009 season has arrived. Medicos has updated its position paper which has the following summary statement at the top. The rest of the document is attached, and it will be posted on our websites.
FAMILY MEDICINE-er-ob for the Uninsured

Clinical Guidelines from Medicos para la Familia www.medicosmundial.com

www.psot.com

1.   Improve health care by minimizing fragmentation of health care and maximizing treatment at the point of service seven days a week.

2.   Use generic medications when they are equivalent.

3.   Minimize antibiotics for self limited infections.

4.   Teach awareness of risks generated by high cost, fragmented, hospital ED visits.

5.   Gather data describing the benefits of expanded Family Medicine and tell this to the public.

Prepared by Wm. MacMillan Rodney MD

 Original 11.2.99 (Updated 08-10-18 wmr)

Recently edited  changes

C.     An 18 mo toddler with a 2d history of decreased feeding, irritability, and a “fever” is noted to have an oral office temperature of 102.4 F and normal TM’s. In both cases the pharynx is pink without exudate, lungs are clear, there is no adenopathy, the neck is supple, the child makes eye contact, and the mucous membranes are moist.

1. Education regarding “fever phobia” with specific mention of febrile seizures and newer studies indicating a lack of brain damage. MANY OF MEDICOS’ STAFF HAVE FEVER PHOBIA—EDUCATE, EDUCATE, EDUCATE!!!!!! See the Patient Education File in Practice Partner. There is a specific handout on fever phobia.

2. Buy time with mild "tonics"--Periactin, robitussin[aka by the generic Siltussion DM], Chlortrimeton qid x 2 days. Return if not better in one or two days.

3. Understand the “Yale Child Observation Score” as a way of identifying serious versus trivial childhood illness. Playful alert children making eye contact are not seriously ill.

 4. “What to do for colds in kids”--I suggest nasal saline sprays/irrigation (depending on age/willingness of kid), tylenol for fever/aches/grumpiness, hot salt gargles for sore throat (plus popsicles!), and lots of kids/parents like the (?Vicks) chest "patches" with "menthalatum".  Honey in hot tea too.  I spend lots of time explaining the futility of abx/cold meds.  The school nurses still kill me by telling folks to take the kid to the doc for "medicine"....
Debbie Sutcliffe, MD;  AAFP list serv 17 Oct 2008

D.      PENILE RASHES

www.psot.com

Index--drug guidelines, penile creams[8-8-08]

1. Patient #50455 with "balanitis" received steroid cream and antifungal cream...  I believe that our policy is that creams are NEVER to be used on a penis.... Dr. Rodney, please tell me if this is true.
Dr. Bangura saw him today and discontinued all of the creams. Conchita

2. WMR REPLY--This is a guideline which differs from a "policy".

Especially among uncircumcised men, which includes many among the Latino community, rashes and abrasions on the glans and foreskin are prolonged by creams and ointments. This is one of a variety of medication prolonged and medication induced illnesses we see in a society recommending Neosporin ointment and Bacitracin cream for every cut and scratch. I literally have to pry the tube out of the hand of some women applying creams every hour on the hour after their child's circumcision. The cream leads to complications and impedes healing.

Worse yet are the over the counter sales of steroid creams which are inappropriately applied to otherwise self limited illness. Great for business, but bad for the patients.

Even among circumcised males, most of these "rashes" are the result of sexual abrasions and they are almost always self limited if allowed to dry out and close over. Rarely are they actually infected. When they do become infected, as in cellulitis, they require oral antibiotics. Testing for other sexually transmitted diseases should be considered, and/or empiric treatment given without cultures. This means Rocephin IM and doxycycline for 7 days. Bactroban has not been approved for this use in this location.

 
Index--Required Reading physicians-generic meds, prescribing guidelines, uninsured health care, generics, flu season
 

OB Billing Policies

POLICY:

Medicos physicians must review the prenatal database on a weekly basis and change it for deliveries, transfers, drops, and other appropriate information. In the case of drops or transfers, physicians only have 90 days in which to file for the prenatal work which was performed. Therefore,  physicians and staff must notify billing staff such that charges can be filed. At a minimum there will be a monthly review of the prenatal database.
 
In response to the following:
 
THERE IS NO INFO ON WHAT HAPPENED TO: @ NASHVILLE

#67966 LAST SEEN 8/25/08
#68034 LAST SEEN 8/24/08
#67472 LAST SEEN 8/14/08
#68506 LAST SEEN 8/22/08
#35897 LAST SEEN 8/14/08

PLEASE ADVISE. THANKS!

I am asking to notify billing sooner than due date when dropped, missed ab, elective ab, or any case they are no longer our patient because we only have 90 days from date patient was last seen for ob care to bill any prenatal visits. Please?! These patients are cash so they dont matter but anyone with insurance we have a time frame for billing.

Thank you for all your help,

Amy

We are enthusiastic about our information management system, but the human software needs constant maintenance..
 
I was trying to convince the Nashville doctors and staff to put a note into the database when the patients have obviously dropped out. At that point they have to tell billing. Usually, we wait until their due date or until a certified letter. At that point the database should have a note telling billing staff to bill for prenatal visits if Tenncare, or to drop the balance if uninsured.
 
When you see cases falling throuugh the cracks, please bring them to my attention so we can educate. All the physicians need to use the information system, but it is not intuitive.
 
 
 
Wm MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
ABPS Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural Tn.
www.psot.com

Index--Billing, OB, transfers and drops

A Unique Value Within The Community PT.2

 

 
Below is the photo and a radiographic image on the uninsured newly diagnosed diabetic who presented with this lesion on the fifth digit. Vital signs stable but glucose 407 mg%. WBC = 10.3(normal) No ketones. It's Saturday and he thinks he might have insurance with his employer who is not available until Monday. The county hospital for uninsured patients is on diversion, and the ER doc informs us that she will "turn us in" if we send the patient to her hospital. Are we having fun yet? Is there anything Medicos can do for him? If we were in Guatemala,what would we do?

QUESTION:

Can that be amputated under local in the office, and then daily injections of ceftriaxone?
 
REPLY:

We will try to get him admitted to the hospital here in Memphis. Probable amputation but IV antibiotics and insulin in the office while we sort out the payment and other psychoscial issues..
 
In America, amputation will occur in the hospital, but some mission hospitals are not as well equipped as our office. The surgery can proceed only if the patient and family acknowledge the risk ofr needing additional surgery if the first one fails.

Osteo is well advanced into the metatarsal, and likely well up into the foot so simple toe amputation would not "cut it". I would take your side if the ER doc turns you in however, since this is a limb threatening infection. In Thailand (similar to Guatemala) I would have debrided completely in the minor O.R. under ketamine, and just rolled out another cot into the hall ! (good case for the MSIV to do actually)

Gram Stain would be helpful in picking the right antibiotics, but likely will need Vancomycin for MRSA coverage, although Gentamycin might be an alternative as daily IM until you can squeeze him into a hospital bed.

John Gibson, MD
John Peter Smith FMR
Index--addtion to posted blog, xray in office, office ortho

Index--foot lesion, osteo 08-19-4

Office Surgery As A Revenue Center

Family Medicine is a tree which has been lost in a forest of generic primary care. The Medicos plan is to educate the public and ourselves about the need for expanded services as a healthcare benefit valued by the public. Office surgery is a revenue center for the office as well as an outstanding market niche for the advanced practice family physicians of Medicos. Memphis and Nashville have repeatedly seen patients who, by word of mouth, bypass other facilities because of the office surgery services available only at Medicos.
 
Originally this page was dedicated to GI endoscopy, but it has been expanded to include other office surgeries which use  IV sedation and analgesia. The administration of parenteral anitbiotics has emerged as a legitimate service for the uninsured non-English speaking patients who regularly present to Medicos with severe infections and sepsis. Attempts to refer these patients to safety net hospitals have not been uniformly successful.
 
Medicos will be considering an expansion of its hospital services with the addition of Drs Gailmard, Chiu, Yibirin, Singh, and others. Friday's conference included a workshop on the use of these forms for these patients. Physicians will receive 50% of collections for services on hospitalized non-OB patients.
 
 As a service to the community Medicos has not increased its charges for over 5 years. But the one page attachment is an important review of common services, codes, and charges. This part of the practice management curriculum has been updated and attached. Please review it and offer comment.This will under go one more revision.

Index--Billing, Forms for the office, Office Surgery
 

Emergency Services Create A Unique Value In the Community

Attached you will find the revised list of Emergency services which occur rarely, but create a lot of credibility for Medicos as a unique value within the community. I hope we can develop these services in Nashville with some frequency. I definitely see a trend for these services on Saturdays. and Sunday PM's. If Medicos could develop a critical mass of physicians providing these services in the community, family medicine would have a tremendous advantage over the minute clinics and other generic primary care offices.
 
Today Medicos Memphis had a new onset 43 yo Latino male previously undiagnosed diabetic with a foot infection. The foot was grossly infected over the fifth digit and draining pus. Glucose 420 and HgbA1c over 10%. No previous hx. CBC WBC was 10.3 with stable vital signs  No insurance. No streaking up leg. Should Medicos immediately refer?
 
Medicos started an IV and immediately gave several IV antibiotics. 15 U reg insulin given. IV demerol given slowly to allow debridement of pus and necrotic tissue on 5th right digit  4th digit becoming involved. Would an xray be helpful?
 
Xray demonstrates  fifth digit and distal 5th metatarsal bones have been eaten away by osteomyelitis probably. Debridement under local anesthesia and sedation analgesia, indicates fifth digit without tendinous and bony attachments. Where do we go from here? Wife is in attendance and communication is good.
 
First we chose to give care rather than "turf" to the ER where we have had some really tragic "turn aways" for uninsured patients. Medicos will follow this patient tomorrow with antibiotics, wound care, and insulin (We are the only ones open Sunday). Then Medicos will involve social work and hospitalize on Monday. We will try to admit this patient to Medicos' service in the hospital. From there we will coordinate surgical, infectious disease, and diabetic care consultants.
 
We anticipate that emergency medicaid will be located for this critically ill patients. But he could easily fall through the cracks, and for this reason, we will stick with him. This is the third similar case in the past week.
 
Therefore Medicos is creating an ER services resource which highlights the hours of "critical care -intra service time" and the "IV infusion time" necessary for the care of these patients in the office. Care of these patients requires several hours of face to face care time, multiple labs, and multiple treatments by IV. These codes allow family physicians to legally create $700-$1000 in charges for these potentially life saving services in the office. They are the sine qua non for mission hospital service.
 

 " Medicos-where 10 percent of the information makes over 90 percent of the difference and where,through Grace, twice the service is provided at less than half of the cost." Constructed and maintained without government grants or charity. A design laboratory for the development of mission hospitals and independent physicians provide continuing comprehensive health care unrestricted by age, gender, organ system, and location of service. A rural simulation in urban-suburban Tennessee.

Index--Forms, charges, ER in office