REPORTED BY
NORMAN J CLEMENT RPH., DDS, NORMAN L.CLEMENT PHARM-TECH, MALACHI F. MACKANDAL PHARMD, BELINDA BROWN-PARKER, IN THE SPIRIT OF JOSEPH SOLVO ESQ., IN THE SPIRIT OF REV. C.T. VIVIAN, JELANI ZIMBABWE CLEMENT, BS., MBA., IN THE SPIRIT OF ERLIN CLEMENT SR., WILLIE GUINYARD BS., JOSEPH WEBSTER MD., MBA, BEVERLY C. PRINCE MD., FACS., LEROY BAYLOR, JAY K. JOSHI MD., MBA, ADRIENNE EDMUNDSON, ESTER HYATT PH.D., WALTER L. SMITH BS., IN THE SPIRIT OF BRAHM FISHER ESQ., MICHELE ALEXANDER MD., CUDJOE WILDING BS, MARTIN NDJOU, BS., RPH., IN THE SPIRIT OF DEBRA LYNN SHEPHERD, BERES E. MUSCHETT, STRATEGIC ADVISORS
“Let’s stop pretending we care about people and make protocols to protect people that we may not care about.”
BY
BEVERLY C. PRINCE MD., FACS
THE PERCEPTION OF COLOR IN HEALTHCARE DELIVERY
Just about everyone is willing to admit, the American Medical Association of Practitioners is not where it wants to be when it comes to handling the Signs and Symptoms of Disease in African Americans.
One obvious way, was when a friend of mine, a practitioner kept noticing his eyesight worsening.
He was referred to an Ophthalmologist who, after his exam, ran a simple blood test that leads to his being diagnosed with colon cancer.
He was fortunate enough to be cured with surgery.
All of his doctors were in an uproar, how could they have missed his complaints of-
- Fatigue
- Occasional cloudy head
- Feeling slow
- Low energy
- Muscle cramps
- Difficulty sleeping
- Eating ice
- Swollen tongue (glossitis) smooth, burning?
- Nail abnormalities (dips in middle)
- Anxiety, depression and difficulty concentrating
Well, it was easy to miss these signs when his tendency to downplay them. And in fairness to him, he was not eating ice and doesn’t recall his tongue burning.
Now I am being specific when I say African Americans because I am comparing them to white Americans in the same health care system. If you said his symptoms were too common then I will give you another patient.
perceiveED NOT WORTHY OF CARE
She is my intelligent sister who comes to the ER obviously high and orientated to place, person and time. She is not really certain why she came and the doctor only became aware of her because she started yelling about how long she’d been there.
The doctor immediately started to defend the Hospital and staff, I guess, why else would he be defensive? And answers, “I know you’ve been here, we are very busy”. Then he comes over and starts sparing with her, specifically, why is she in the ER?”
When she answers too slowly he walks away without reviewing her chart, or taking advantage of this moment to perform a quiet exam?
When he comes back, about 40 mins later, she complains of her arm, he gets an X-ray and one and half hours informs her of a fracture”.
He laughs when she says, “I told them it wasn’t broken.”
He leaves calls the orthopedist and comes back with a name and phone number for her to call.
He puts her in a cast and sends her out. As she leaves she repeats that she didn’t think it was broken.
THE DIFFERENCE OF CARE IS OFTEN WHO IS IN CHARGE
Last, this patient has epistaxis and has come to the ER a third time. This time the ENT is called and the patient visit goes like this.
“I took the packing out of my nose because it hurt and it wasn’t working it was coming our any way, and blood started coming out of the other side.”
I asked the patient if she is hypertensive, she says no.
I inform her that since this is the third packing, she might not be able to tolerate it. She says she can because she has to attend a function for her youngest child after work, and she can’t have surgery, especially if there is a possibility she will have to be admitted.
I order Ativan I.V. Which she refuses until I tell her again, how painful packing may become. She asked why I don’t give her pain medication, and I tell her I am also trying to calm her which also makes things hurt less.
I anesthetize her mucosal membranes, locate the bleeding septum as I discuss the need for the clot to form, and then organize. She tells me that she has an associate’s degree in nursing and has read about blood clots. She says that hearing me talk like that is reassuring.
After she is packed, we let her sit quietly for an hour, and I ask her E.R. Doctor to, begin to treat her blood pressure, and refer her to her PCP to continue treatment. I give her an antibiotic IV with an oral prescription, give her three days of antihistamine/decongestant, with a narcotic pain reliever for three days.
I will see her in three days or she will follow up with an ENT in three days. Oh, and give her a note to stay off work, she works in a nursing home, no bending, lifting or stooping for three days.
Ok class, what is the difference in treatment for the first two and the last?
The first is:
1. Who was in charge?
WHEN YOUR MEDICAL KNOWLEDGE IS BEING UNDERMINED
I once worked in a trauma center in upstate New York where I would routinely cover up the patients waiting to be seen. I managed to alienate the other practitioners to the point of being bullied.
The Physician Assistants decided I didn’t know what I was doing and expressed it to everyone and anyone who would listen. The E.R. Director of the Trauma Center eventually decided I was “disrupting” the staff’s usual functioning.
Needless to say my treatment of the epistaxis would have been perceived as “excessive” had I not been in charge of an area no one else could handle.
The time I took was seen as “necessary”, the Ativan IV was given because they could see the nasal passages where inflamed from repeated attempts, and the medication for hypertension was sustained by the Obamacare Electronic Records, that noted every time she’d come to the E.R. The patient had an elevated diastolic and systolic measure that was not addressed (in writing).
Oh, and the pain medication,, the opioid pain medication was understood in hypertensive who had been packed three times. The antibiotic, which was a pearl, helps to heal in the traumatized nasal cavity.
DEVELOPEMENT OF PROTOCOLS THAT ELIMINATE POOR TREATMENT
I am declaring a need for people who can handle the illnesses of African Americans. I recognize these people as those who
1. See problem
2. Are willing to change their behavior
3. the development of scientific led Protocols.
And of the last is the one I have the most faith in. The development of a set of rules to govern how we deal with African Americans (and eventually others) who present to the E. R.
First by realizing we owe African Americans a “repair” of damage done to them by poor treatment in E. R. Systems and second a willingness to add monetary and fiduciary costs to support the protocols.
We are all concerned the Information Age will exclude many who are not prepared. Those without the resources for computers or the resources to learn computer skills will exponentially find themselves “caste” aways unless their need is identified by the information they give and treated by those capable of transforming the information into behavior patterns.
Now, let us use this new system with the first patient.
The High Achieving African American medical Provider
- Incentive for Blood Work and vital signs- A yearly CBC, CMP, and Vital Signs Assessment
- Incentive and extra money for E.R. Who treat higher percentage of African American Patient
So when the African American presents to an ophthalmologist, he or she be offered CBC, CMP, HgbA1C along with visual, glaucoma.
Make Vital Signs part of any medical exam (and paying for extra time for explanations)
E.R. Visits that lead to a medical referral and completed visit is rewarded in income.
E.R. Visits that treat outside ICD code of visit, rewarded with income.
The way I would have treated my sister who seemed high, was CMP and CBC, HgbA1c drug screen. This new protocol makes no assumptions. Even drug and alcohol testing may reveal dangerous levels and explain how you may best serve this customer we in Medicaid call patients.
Then get someone to explain she has a fracture and this is a break in her arm, and remember you don’t know how long she has had it, but now you understand why she has been self-medicating her very painful injury. Though you still can only quests how she got it.
Make that person you assigned to her find out for certain that she is safe and has a place to stay. Let’s stop pretending we care about people and make protocols to protect people that we may not care about.
Last, if you can’t be certain she will comply and see the doctor you are referring herE to, and you can’t. Then, test her for a compartment syndrome before she leaves in order to establish a baseline, make certain she doesn’t have a compartment syndrome.
The difference in the care for this patient is being paid to test her blood levels for an ICD bone fracture, and a new ICD called unknown timing of fractured limb. This gives the provider a way to subjectively admit he is uncomfortable with a patient and objectively document care.
But most important the hospital should be reimbursed for these tests using the ICD code of uncertainty rather than simply fractured bone.
FOR NOW, YOU ARE WITHIN
THE NORMS
