Skip to main content

Posts

Showing posts from March, 2014

Principles of Critical Care Medicine for Non-Intensive Care Specialists: Harvard Medical Education at its best

I just got back from Boston where I visited friends and went to a really good and useful Harvard Medical school continuing medical education course. Harvard is one of the few institutions that I have found to have consistently good classes for practicing physicians, with a few exceptions. This Spring I wanted to get myself to Boston and so I went to the online list of Harvard CME courses, which is more exciting than a candy store. In the time block that I had available they offered two delicious options. One was a week long course on everything anyone ever wanted to know about internal medicine which would have earned me over 60 hours of credit while crushing my soul with 10 hour days of densely packed information mainly intended to help practicing physicians pass their board exams. The other was the course that I chose which delivered almost 20 hours over 2 1/2 days, leaving me time to walk along the waterfront and eat a little lobster and even frolic with my friends.

The course, th…

Tranexamic acid--why you may be less likely to bleed to death in Britain than in the US if you get injured

The other day at an interdisciplinary rounds meeting at the hospital, one of our nurses who is also an emergency medical technician mentioned that in Britain injured patients receive tranexamic acid before arriving at the hospital because it reduces death from bleeding. "What's that?" I said. I kind of barely remembered hearing this medication's name associated with the treatment of a rare disease, but not treatment of trauma. So I was guessing that this was some drug that was invented long ago which had been found to be quite effective in other countries, but has not been really optimally used in the US because it is generic and therefore unlikely to make drug companies money.

Bingo.

Here's the story, as far as I can determine.

Tranexamic acid is a relatively simple cyclic molecule that blocks the fibrinolytic process, that is the natural breakdown of blood clots in the body. In the setting of any injury, especially severe ones, fibrinolysis is intensified, lea…

Critical Access Hospitals--the 96 hour rule and other ridiculous and self defeating requirements in Medicare's payment for small hospitals

My home hospital is small. In a town of just over 20,000 people, this hospital has 25 beds and is designated "critical access" by Medicare because it is felt to be necessary to the health care of the community. Critical access is a designation which was introduced in 1997 when modernization of Medicare payment systems threatened to close a large proportion of hospitals in small communities which were unable to benefit from economies of scale. A small hospital needs to remain capable of providing services to small but significant floods of patients when everyone gets sick at once, and maintain skills and staff to care for a variety of different diseases. This can make such a hospital less financially efficient (though various other factors can partly offset this) and the critical access program spares my hospital some of the Medicare belt tightening that would make admitting Medicare insured patients prohibitively unprofitable.

Most larger hospitals are now paid for their Me…