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Medical Tourism

We recently had a woman (just last month) who came in with a post-op issue that would require another surgery to repair. I told her most surgeons won’t touch another surgeon’s patient if there is a problem, because they don’t want to get sucked into the lawsuit that will likely result. That was when she dropped the factoid on us- the surgery had been done in Costa Rica because the surgeon, hotel, and air fare was about one third the cost as having the surgery done here. We tried to get her admitted to have it repaired, but we couldn’t find a single surgeon willing to take the case.

It’s like trying to find a carpenter who will remodel your house while the house is on fire.

As an emergency nurse, I periodically (a couple of times a year) see patients who come in with post procedure complications. There was the woman who had to have her right ass cheek removed when the silicone injection she got in South America became infected.

The fact is, it’s cheaper to have these things done in other countries because the standards are lower there. You are rolling the dice.

I understand the draw- my own doctor is screwing me over. Back in February, I went in for a 6 month checkup (I go every six months because I am diabetic). The visit was billed to insurance at $500. The blood work (CBC, CMP, TSH, A1C and a Lipid panel) was billed out at $2399. Insurance got it down to $1408. For routine labs. So the total bill for a semi-annual checkup was almost $3,000. I told the lab that I am not paying that. Had I known what the bill was going to be, I would never have agreed to it.

I agree that medical billing is deceptive and often high. There is no way to know what they will bill you ahead of time, because many won’t post a price list. I can understand saying “Hey, we can’t tell you what this hospital visit will cost, because we don’t yet know what the problem, the testing, or the solution will be,” that makes sense. What doesn’t make sense to me is how a hospital won’t disclose what they charge for a CBC, or a CT scan. Trump tried to force that, but the stupid TDS sufferers and the health care companies banded together to defeat it.

Our health care here in this country is great. It’s the deceptive shell game pricing that is the issue.

By Divemedic, ago

Likely Not the Cops

I know I give cops a lot of shit on here when they screw up. This case out of El Paso is not one of those times. Let’s watch the video, then we can discuss it.

Watching the video, it appears like this man is on some sort of drugs. This isn’t a mental health breakdown in my opinion. The cop uses his TASER.

There are some in comments to the above post, claiming the TASER was used too many times and stopped the man’s heart. That’s not the case. A TASER delivers 3 joules of energy. A defibrillator delivers 200-360 joules to an adult heart. There simply isn’t enough energy in a TASER to stop a person’s heart. In the cases of in-custody death that occurred after TASER deployment, it turns out the decedent had cocaine on board nearly every time.

One thing that may have contributed to the death was something called positional asphyxia. When a person is handcuffed with his hands behind his back and is placed in a prone position, the chest can’t fully expand and the person can die as a result. In that case, the cops would have been at fault to at least some extent. A person whose hands are cuffed behind him MUST NOT be placed in a prone position, especially if they are already exerting themselves in an attempt to breathe, such as immediately following an extended wrestling match with arresting officers, as per guidelines from the US Department of Justice.

The cause of most explained in-custody deaths is a little-known phenomenon called positional asphyxia, in which body position interferes with the ability to breathe. Several pre-existing factors are identified that increase an individual’s susceptibility to positional asphyxia, including cocaine-induced frenzied behavior, other drugs and/or alcohol intoxication, violent struggle resulting in restraint of subject, and unresponsiveness during or immediately after struggle. A subject’s pre-existing risk, coupled with their body position when subdued or in transit, can combine to substantially increase their risk of sudden death from positional asphyxia. 

This is why I recommend to all paramedics and nurses that they not transport or treat anyone whose hands are cuffed behind their back, especially not in a supine or even prone position. The patient should be sitting up, or can have both hands cuffed to a bed or stretcher. The Joint Commission (TJC) standards outline strict rules and requirements for managing patients in restraints or seclusion, emphasizing that these measures are high-risk emergency interventions.

Hospitals must have explicit written protocols detailing continuous or frequent observation:

  • Patients must be monitored continuously or at frequent intervals determined by hospital policy (often documented every 15 minutes)
  • Restraining a patient in a prone (face-down) position is highly restricted due to the severe risk of positional asphyxia; patients should typically be kept in a supine position with the head of the bed elevated if aspiration is a risk
  • Staff must regularly assess and document the patient’s physical status, including vital signs, skin integrity, circulation in restrained limbs, hygiene, and the offering of nutrition, hydration, and toileting

Still, I think (looking at this video) the base cause here was whatever drugs were in this man’s system.

By Divemedic, ago

Drug Administration

A hospital in Nashville recently severely injured several patients when they administered potassium phosphate in place of the anesthetic Polocaine. In order to understand how this happens, it’s important to understand how medications are given in a hospital setting. This is dictated in general terms by the Joint Commission, a U.S. nonprofit organization that sets safety and quality rules for hospitals and medical centers. In order to be certified, one has to conform to the rules and guidelines of the Joint Commission. The commission inspects every hospital every three years, and will also inspect a hospital if they have had sentinel events. Here is generally how medication administration goes:

  • When the patient checks in to the facility, they ae identified by multiple identifiers, including name, date of birth, address, and others. This ensures the hospital knows which person they are dealing with. A wrist band with a barcode matching the patient’s record is placed on the patient’s wrist.
  • The intake nurse reviews medication allergies, current medications, and medical history with the patient.
  • In many cases, a pharmacy representative will repeat the verification process.
  • The provider orders the medication that will be given.
  • The hospital’s computers check to make sure the medication is proper, and there are no contraindications for the medication. If it finds any, it will alert the provider to the issue, but the provider can override this recommendation.
  • A pharmacist reviews the patient’s record and the medication order to ensure the order is proper, the dose is correct, and the patient has nothing that will contraindicate this medication. It’s then released. Sometimes, the medication has to be mixed in the pharmacy. There are complex procedures for doing this as well, with numerous safeguards in place. Still, mistakes DO happen.
  • The nurse who will administer the drug pulls the medication from the drug cabinet, which is locked and keyed to the nurse’s fingerprint and the patient’s name. Doctors do not have access to this system, only nurses and the pharmacy can open the cabinet.
  • In case of emergency, if the pharmacist hasn’t approved the medication, or a provider hasn’t ordered it, some nurses can override this and pull out a medication that hasn’t been ordered. Sometimes it requires a second nurse to also use their fingerprint to access the medication. Each unit has its own rules as to who can do this. The nurses in the ED, ICU, and other high acuity units have more latitude than do nurses from other units.
  • Some medications are marked with brightly colored bands that say “high risk medication” as a visual warning that the drug can be particularly dangerous if given improperly. In those cases, two nurses are required to administer the medication, to further reduce the chance of error.
  • The nurse then uses a computer at the patient’s bedside to scan their wristband to positively identify the patient. A prudent nurse will also ask the patient their name, date of birth, and which medications the patient is allergic to.
  • Then the nurse scans the barcode on the medication, and at this time, the computer matches what was ordered and approved to what was just scanned. If there is a mismatch, the screen gives a bright red warning overlay, telling the nurse that there is a problem.
  • As a final check, the nurse administering the medication is expected to check the medication, dose, route, and other facts to ensure the drug is safe and proper for that patient before they actually administer it.

All of this is designed to minimize the chances of a medication error, but there are numerous places where someone can take shortcuts and the result is a patient getting the wrong drug. In the case of Polocaine, it is administered by a nurse anesthetist or doctor. It can be pushed in manually, or can be given by an automated pump- in both cases directly into the spine.

Although I have no direct knowledge of this specific incident, here is what I suspect happened. The hospital says it was a pharmacy error. In the pharmacy, Pharmacists or certified techs prepare it inside a sterile, laminar-flow hood to ensure complete sterility. The ingredients to be mixed are placed on a table and photographed for later tracking. A second person (usually a licensed pharmacist) then checks the medication to ensure it is correct. They are then mixed, a tracking tag with a barcode are placed on the medication, and it is sent to the point of use. With some medications that are high risk, more than one person is required to sign off on the blend to ensure there were no mistakes.

It seems likely the pharmacist or tech who mixed the drug put the potassium phosphate in the medication instead of the Polocaine, and the person whose job it was to check it just signed off on it without looking. People tend to make these sorts of mistakes when they are overloaded with tasks. I’ve had this mistake happen three times in my career, and each time I caught the error before I gave it to the patient. Once was with half normal saline being confused for normal saline, the second was a unit of packed red blood cells that were not properly matched, and the third was a bag of phenobarbital that was improperly mixed. The mistake with the phenobarbital was unusual, as it was the hospital’s computer that made the error, and a subsequent investigation showed this error was system wide, with hundreds of patients receiving the incorrect medication. I was just the first person to catch it. It seems likely that some patients experienced negative consequences, although no one can really know for sure.

Administering medications is one of the riskiest things a hospital does. A busy hospital gives medications millions of times per year. Every step and precaution is taken, but no policy or procedure is 100% foolproof. This is why medical careers like nursing, pharmacy, doctor, and others have such high barriers to entry and licensure. We could have cheaper healthcare by lowering those barriers and creating more licensed personnel, but we do so at higher risk of errors.

By Divemedic, ago

COVID

So facts about COVID from someone who was (eventually) on the front lines. You can read my reports on things to your heart’s content by clicking here. It’s a chronicle of COVID as we lived it.

When COVID first came around, I was still teaching high school, but my son was working in the emergency room in Harlem. The things he reported to me and saw with his own eyes were incredible. COVID was certainly killing people, and it was doing it wholesale.

The hospital ships sent to New York went largely unused. Not because there were no sick people to be had, but because of the requirements. Patients had to be sent there with a 30 day supply of whatever medications they required. They couldn’t have an active COVID infection, and those are just the two I remember. I know there were more, but that’s what I have after 6 years.

The stories he told had me convinced it was real. It’s what pushed me to come out of my semi-retired life to go back to medicine. I spent the first eight months of my return working on the COVID wing for some of my shifts. The hospital had a COVID wing because all elective procedures had been cancelled, and they were using the floor for that for COVID patients. The things I saw convinced me that COVID was real. I am also convinced it was an engineered bio weapon.

COVID was a real pandemic, hospitals were being overrun, and that is just how it was. So why were there videos of nurses dancing? Nurses have specialties, and it takes years to retrain a nurse in a different specialty. If you look closely at the areas where the dancing videos were taking place, they look like PACU to me (Post Anesthesia Care Unit). That is an area where nurses care for patients after surgery. Since all elective procedures were canceled, the majority of surgical nurses had nothing to do.

So many people were hospitalized for it because there was a financial incentive. Hospitals were paid extra for COVID patients, so they tested everyone for it. If you broke your leg and had to be hospitalized, you got a COVID test. If it was positive, that Dx got added to your chart, and the hospital made more money.

Ivermectin doesn’t seem to really help. I tried it. No other treatments really work, either. It’s a virus, and most viruses have to simply run their course. The vaccine doesn’t do anything. I took two doses of the Moderna vaccine and still got COVID three times. Still, as infectious diseases do, they kill in their early form, then become deadly as the generations go on. That’s just how viruses work. It just amazes me that it became less deadly so quickly.

Infections kill. That’s a fact of life, and it’s your immune system that decides whether or not you die. It’s either up to the task or it isn’t. Especially with viruses.

Do I believe the US had a hand in creating the virus? I do. Do I think Fauci was part of it? I do.

By Divemedic, ago

COVID Gaslighting

We live in a high trust society. If someone tells you the lettuce is safe to eat, we have to trust that it is. If someone tells you this particular treatment will fix the clog in your heart’s blood vessels, you have to trust that it will. After all, no one has the resources to independently verify every statement made by another. I trust people all day- I trust that the medicine in the vial marked “Toradol” isn’t actually “Rocuronium” and my patient trusts that I know what I am doing when I give it to them.

That’s why I get so angry at the left’s current whitewashing of Fauci’s behavior during the pandemic, and their gaslighting of what actually happened. The left is busy claiming Fauci never said the lack of symptoms wasn’t an indicator of having COVID, and that he never said getting the vaccine would prevent you from getting COVID. We have receipts. Here is Fauci saying (sorry video won’t embed):

At the beginning of the COVID-19 pandemic, Fauci originally discouraged mask-wearing by the public because he was concerned about PPE availability for health-care workers. “We didn’t realize the extent of asymptotic spread…what happened as the weeks and months came by, two things became clear: one, that there wasn’t a shortage of masks, we had plenty of masks and coverings that you could put on that’s plain cloth…so that took care of that problem. Secondly, we fully realized that there are a lot of people who are asymptomatic who are spreading infection. So it became clear that we absolutely should be wearing masks consistently.

Then here is FAuci in the spring of 2021 saying that you likely won’t get COVID if you’ve been vaccinated (except limited breakthrough cases):

When people get vaccinated, they can feel safe, no matter what circumstance they are under.- Dr Fauci

Now every one of us remembers that narrative changing to “the vaccine makes COVID less severe” and “you are less likely to be hospitalized” if you get the vaccine.

The left is busy protecting the US Doctor Mengele- except this guy is responsible for enough deaths to make Mengele look like an amateur.

The left is busy screaming about NYC wanting to place Netanyahu under arrest for the deaths of 73,000 people in Gaza. We can’t touch Fauci, thanks to Biden’s pardon. I have an idea- let’s go to the International Criminal Court, and turn over every bit of evidence we have to the Hague, and let THEM prosecute him, since no American who lost a loved one has seen fit to mete out some frontier justice themselves.

All of this nonsense is destroying our high trust society. No one believes anything that anyone else has to say. Let’s end it now.

By Divemedic, ago

Tourniquet Conversion

Scientific knowledge evolves. As mankind discovers more information, the view of our world and how it works changes as well. The use of tourniquets, which I have discussed at length a couple of times on this very blog, are a great example. We were once taught that, once a tourniquet goes on, it stays on unless the patient is in the room with a trauma surgeon. That turns out to be only partially correct.

At the end of the day, trauma is a surgical emergency. What a trauma patient needs is access to that trauma surgeon. Getting a patient to the hospital within a rapid timeframe, often referred to as “the golden hour” greatly increases the patient’s chances of survival. Remember that serious trauma is first and foremost a surgical emergency. Trauma patients don’t need a tricked out first aid kit- they need a trauma surgeon. All they need you to do in the field is keep them alive and prevent them from furthering their injury until they can get on the operating table.

For that reason, tourniquet training for most Americans has followed simple, strict guidance: apply one high and tight to limbs to stop life-threatening bleeding, and leave removal to advanced medical care personnel. That is no longer the case.

So what changed? The war in Ukraine. In the US, and in US controlled battlefields, people who receive gunshot wounds are one helicopter ride away from a trauma surgeon, and the vast majority of the patients make it to the surgeon’s operating table within that hour and have good results. In Ukraine, the nature of the war there is such that almost no one gets a helicopter ride, and with killer drones circling everywhere, very few of those injured are transported by ground in anything resembling even the “golden day or two” and, if they are wearing a tourniquet, wind up wearing it for days. Casualty evacuation in Ukraine often exceeds 6 hours, and the liberal use of limb tourniquets may have increased morbidity.

That sets up a whole list of new problems.

Leaving a tourniquet on for hours or even days causes other issues. Once a tourniquet is in place, it stops blood from flowing to the affected limb. Once deprived of their blood supply, those cells begin taking measures to protect themselves, and after a period of time, those cells die. As they die, they release their contents into the surrounding tissue. When the tourniquet is removed, those contents make it to the kidneys and clog them up with all of that debris. The condition is called rhabdomyolysis. The longer a limb tourniquet is in place, the higher the risk of compartment syndrome, vascular thrombosis, rhabdomyolysis, and irreversible myonecrosis resulting in major tissue loss and often necessitating limb amputation, kidney failure, and death.

If bleeding is controlled with a tourniquet, attempts to remove the tourniquet as early as possible to avoid the negative consequences are essential. However, if the removal is not done correctly, there is a risk the bleeding that the tourniquet was supposed to stop will also kill the patient. The act of removing a tourniquet (called ‘tourniquet conversion’) is now changing the training being put out to US special forces troops, and is especially important to preppers here in the US.

What this means for you

In the US, we are usually a quick helicopter ride away from a trauma surgeon, but that may not always be the case. In a disaster or TEOTWAWKI situation, those helicopters aren’t coming. At the same time, a tourniquet left on for more than 2 hours can itself be a hazard. Before attempting this, please review my post on treating gunshot wounds that you can find here.

Important: Never attempt tourniquet conversion if the patient is in shock, the wound cannot be continuously monitored for re-bleeding, or if the tourniquet is applied above a traumatic amputation.

Shock being defined here as the loss of consciousness, or a blood pressure less than 90/xx.

The Conversion Steps (The “Plus-1” Method)

  1. Prepare: Place a second, loose tourniquet on the bare limb just above the first one, but do not tighten it yet.
  2. Pack: Firmly pack the wound cavity with hemostatic gauze (if available) or standard rolled gauze, maintaining direct digital pressure for at least 3 minutes.
  3. Dress: Apply a pressure dressing securely over the packed wound.
  4. Release: Slowly loosen the original tourniquet (over at least 1 minute) while meticulously observing the wound for bleeding.
  5. Monitor: If bleeding is controlled, leave the primary tourniquet in place but fully loosened in case bleeding recurs.

Optimal conversion should be attempted within 2 hours of the initial application when conditions are safe and stable. If bleeding restarts upon release, re-tighten the primary tourniquet or utilize the newly placed backup tourniquet.

For more information, see the article Tactical Medicine Tourniquet Conversion or consult the sources below:

Sources:

Misuse of Tourniquets in Ukraine may be Costing More Lives and Limbs Than They Save.

Rethinking limb tourniquet conversion in the prehospital environment (pdf warning)

Tactical Combat Casualty Care skill card: Tourniquet Conversion (pdf warning)

Tourniquet Conversion: A Recommended Approach in the Prolonged Field Care Setting

Tourniquet Conversion: The Critical Skill Nobody Teaches After You Stop the Bleeding (2026)

By Divemedic, ago

What Americans Won’t Do

I’m sure most of you have heard about the contaminated vegetables. The culprit is likely lettuce from Taylor farms thats contaminated with a parasite. The parasite is present in feces and spreads via the fecal-oral route.

in other words, some lettuce picker who had ot took a shit in the field, and now 10,000 people share in their misery.

Illegals: doing the things Americans won’t do.

By Divemedic, ago

But It’s Free

The next time someone tells you how another country’s health care is better because it’s free, show them this.

He called EMS at 1755, again at 1805, complaing of shortness of breath. He was told no ambulance would be coming, but that a doctor would call him back.

Someone finally called at 1907, but no one answered that call or tow others. An ambulance was finally sent at 2112,arriving at 2119.

The man was dead on the floor. Hey, at least it was free.

By Divemedic, ago

Cost

A comment to my post on cashing in:

Very enlightening. Up to now, I assumed it was big pharma and greedy insurance companies that caused health care costs to skyrocket. The correct answer, as it turns out, is all of the above; everything connected to healthcare.

No offence to oldvet, this post isn’t an attack upon him, but is a classic case of supply and demand. The ED wants to open, but there is a shortage of qualified nurses. They have no choice if they want to stay in business- by law, an emergency room has to be open 24/7. So they have to:

  • do whatever it takes to get qualified people to come in: that means paying enough to entice them or
  • lower standards and risk medical errors

Since the US has a climate of legal liability, medical care is a field that has zero room for errors. People who can treat patients without making a single error are rare and in high demand. That means there is a bidding war for their time.

Skilled people cost money, which is why it costs $165 to have a plumber snake a drain. No one wants to look up while having a medical emergency and see the cheapest nurse caring for them- they want the best, or at least someone who is good at what they do.

It takes 3-4 years to train a basic nurse. More than 3/4 of those who begin the education don’t make it.

Then it takes another year to train for the ED specialty. Two more years before they reach a point of proficiency without needing guidance and supervision.

Of the nurses here who manage that seven year slog, just over ten percent are good enough to be board certified in emergency medicine. Only a quarter of those have two board certifications.

In other words, of the 257,000 actively licensed RNs in Florida, 17,000 are Emergency Room nurses. Of ED nurses, only about 2500 of them are board certified. Only about 800 of them have two certifications.

Are two specialties really needed? Certified Emergency Nurse, sure. How about a nurse certified in stroke care? Pediatrics? Trauma? Vascular access? Critical care? Each of those is a subspecialty that is needed in the ED on a daily basis.

Now consider that there are 477 licensed emergency departments in Florida, all competing for those nurses. Everyone wants the best, so those who have multiple certificates and degrees demand (and get) top dollar. My last employer had 162 ED nurses and still didnt have enough for their patient load. That drives up costs.

They only way to eliminate the nursing shortage is to either lower demand or increase supply. Lowering demand isn’t going to happen. Raising supply can be done in two ways:

  • Raise pay
  • Lower standards

In today’s legal climate, lowering standards would actually cost more in increased litigation caused by more medical errors. In the ED, 95% of patient care is performed by nurses. We write orders for imaging, lab work, and treatment. What kind of provider do YOU want at your side during your next medical emergency?

By Divemedic, ago