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(Mis)Adventures in ICD-10


(Mis)Adventures in ICD-10

Just a glimpse into the ICD-10 shows how to code the all-too-common problem of when people are injured on railway vehicles (which are not streetcars, mind you).  I think it is fitting, when talking about ICD codes, to start with the area of train-wrecks...



The Origin of Feces

I got this in my email today from "Living Social."


When I first read it, I thought it said, "Your mother always reminded you to wash your behind…", which makes sense, given the advertising subject material.  I haven't read the remainder of the deal, so we can only guess what the last sentence reads: "Pay $39 to get one colon hydrotherapy treatment that will safely and comfortably remove excess wast from your…" well, I guess from behind your ears, if you use enough hydrotherapy.  This woman, however, seems to have not washed behind her ears because she's sprouting flowers from that spot.  Either that, or the hydrotherapy is successful enough to allow growth of hydroponic plants.

I do wonder about two things in this advertisement: first, I wonder at the serene expression on her face.  Surely, this isn't the face of someone having colonic hydrotherapy.  I would expect that face to look a little more like this:

Expression Fig 20 Terror 253x300

Or this:

 Expression Fig 21 Horror 270x300

Which are both pictures taken by Benjamin Amond Duchenne during an experiment using electrodes.  

Duchenne had set out to find the muscles responsible for creating particular expressions using an electrical device he had originally developed to investigate the muscles that control the hand. He applied galvanic probes to the facial muscles of a number of different test subjects. He also took what today could be thought of as control photographs of the same people with blank expressions, and others where they were attempting to simulate expressions without the aid of the probes.


These photos fascinated Charles Darwin enough to include them in his book on emotional expressions.

Which brings me back to the second observation about the advertisement: the inclusion of a beautiful woman with flowers around her is not necessarily what comes to mind when I think about "colon hydrotherapy."  The below pictures (also from Darwin's book) express to me a more realistic response to the turning of one's colon into a water balloon.

1872 Expression F1142 figplate5

After all, what is inflated must then deflate.  We all know what the end product of hydrotherapy is: Galapagos.

Which brings up the final irony of this offer to put water in my colon for a fraction of the expected cost: it comes from a website called "Living Social."  Do people really believe that colonic somehow gives them an advantage while "living social?"  Perhaps, however, this will work for the benefit of natural selection, as they will have less of a chance to have children.

I think I'll stick with Groupon.



Mind the Foliage

I take care of patients of all ages, but a substantial amount of my time is devoted to routine pediatrics.  I try to make a good impression on the kids, knowing that my care will be a lot easier if they aren’t terrified by my presence.  Those who don’t do pediatrics often say the reason they don’t want to care for children is to avoid “all those screaming kids.”  I want to avoid “all those screaming kids too,” but I do it through good PR.  I joke with them, tickle them, find peanut butter in their ears, and other tactics to make them comfortable.

This approach has an added benefit regarding the other reason doctors don’t want to see kids: the parents.  If the kids like me, the parents are much more likely to listen to me.  One of my favorite things to hear is for a parent to say how their child wants to come and “see Dr. Yamberts” when they are sick.  I periodically have kids running to me at the hardware or grocery stores, throwing their arms around my legs in a tight hug.  It’s my tranquilizer/blood pressure drug of choice.  Life is good when my patients love me.

It is strange to think about me being the image these children have of my profession.  When the word “doctor” comes up, they picture me.  They think of doctors examining under their arms for fictional problems as an excuse to tickle.  They think of doctors having Scooby Doo stickers on their stethoscope.  They think of the doctors office as a place where they can laugh and where they are cared for.

OK, it also helps that I am juvenile in my humor and that I actually enjoy playing with them.  It’s not just PR; it’s self-indulgence.  It’s definitely a win-win.

But I was met with a different reaction from one of my regular patients recently.  I was joking around with this intelligent boy who was at my office with his mother for her visit.  He was telling me about school and about how he likes math problems, but doesn’t like taking the tests.  I started teasing him about the girls in the class - something I take great pleasure doing to boys of a certain age.  They react as if girls are covered with radioactive Ebola virus.  It’s hilarious.

Perhaps it was out of spite, or perhaps he was just being a typical guileless kid, but he interrupted my teasing: “You know what, Dr. Lamberts?” he said, sounding serious in his tone.

“What?” I answered, waiting for his words of wisdom.

“You really need to take care of something…a situation,” he continued.

“And what is that?” I asked.

“You need to cut your nose hair.”

His mom let out a yelp and I started laughing, suddenly self-conscious about my hirsute nares.  He sat there, still serious, as if he had said something profound.

“I’ll take care of that as soon as possible,” I responded when I caught my breath.  “Thank you for letting me know about that.”

Upon leaving the room I went immediately to my office, got a pair of scissors, and trimmed the locks in my schnoz.  It wasn’t all that bad, was it?

It left me wondering how many kids had noticed this and not told me.  How many kids were disturbed by my nasal foliage?  How many kids out there didn’t see me as the funny doctor, or the one who tickles, but the one with the creepy nose hair?

I’ve been obsessing about it ever since.



What are you going to do?

The following is an actual fictional conversation that took place in the doctor's lounge at a local hospital. Internist - Dang, these Medicare cuts are coming and I doubt that congress has the wits to avoid them.  I am not sure I can go on practicing if they cut them any more.

Family Physician - Yeah, we already get paid so little by Medicaid and the private insurers, we have had to start to look for other sources of revenue.

Int - Really?  We have been looking into that as well.  What are you thinking about doing?

FP - We thought about doing cosmetic procedures, but we have an especially good-looking population, so we really can't make it work.

Int - Bummer.

FP - Yep.  Instead, we have decided to open a kiosk for Krispy Kreme donuts.  We figure we can make money off of the donuts, plus we can get more of our patients obese.  Then we can treat worse diseases and code a higher level for each visit.

670px-Krispy_Kreme_10 Int - Genius.  Plus, you can get all of the kids hyperactive on the sugar and treat their ADHD.

FP - And the "Hot Donuts Now" sign along with the scent of fresh-baked donuts will really draw in new customers...I mean patients.

Int - One of the GI doctors in town is doing the same sort of thing, opening a Starbucks in his office.  He figures he gets walk-ins, gets people with worse dyspepsia, and gets free WiFi to boot.

FP - Brilliant.  What have you been thinking of?

Int - We have noticed the interest our patients have in holistic medicine, and thought we should capitalize on that.

FP - So you are hiring a homeopath?

Int - No, they wouldn't set foot in our office because of the "evil" immunizations we use.  We tried to get all sorts of alternative providers, but they would always sneer at our practices.  And so we finally opted for two things: first, we are doing aromatherapy, which has our staff so relaxed that they don't seem to have noticed that we cut their pay by 50%.

FP - Great.

psychic Int - Second, we have a psychic who goes around in our lobby doing palm reading and tea leaves on our patients as they wait.  There are two positive outcomes from this: the patients who get bad fortunes told are so anxious that their blood pressure is up and they are ripe for anxiety treatment; the ones with good fortunes are happy enough that we can order all sorts of tests on them and they don't seem to care.

There is a downside, however.

FP - What's that?

Int - My partner now thinks that we should take our entire budget for next month and invest it in Power Ball lottery tickets.  He says it is a "sure thing."

Hospitalist - Hey guys, what's up?

FP - We're just discussing what we are going to do to offset the impending Medicare cuts.  Do you have plans?

Hos - Oh yes.  I don't like the idea of increasing the load to 70 admissions per day.  50 is plenty.  Instead, we are capitalizing on the fact that our patients are a "captive audience."

Int - This I've gotta hear.

Hos - We figured that we have enough turnover that some sort of direct marketing scheme to our patients could be quite lucrative.  We are now certified Amway sales representatives.

FP - I love it!


Hos - Yep.  We have these patients in a position where they can't move, and we sell them cleaning solvents, vitamins, and skin care products.  Instead of taking cash, we just add it on to their hospital bill, so they usually buy a bunch.

Int - As an added bonus, the families of your patients will be so scared that you will try to sell them Amway products, that they steer completely clear of the hospital.

Hos - Bingo!  It works like a charm.  We got this idea from the intensivists who were holding Tupperware parties in the ICU.  The patients were sedated "just enough" so that they left the hospital with all sorts of cups, jugs, and bowls.

FP - Any complaints?

Hos - Not yet.  You figure, what we charge for the solvents is 1/4 of what the hospital charges for an Aspirin.  The patients really don't notice a little more charge.  We have even had some insurances mistakenly pay for some of our Amway products!

Int - You know, maybe this Medicare cut may just be a good thing.  Look at how it has pushed us to open new frontiers in medicine.  Our children will look back on this time as being one of the real turning-points in American healthcare.

FP - Yeah, today Amway...tomorrow....

Hos - Healthcare reform?  Higher reimbursement?  A fair payment model?

FP - Used Cars.

Int - I am so glad I went into medicine.



Ode to a lost companion

I recently replaced my beeper with a cell phone. It is the first time I have been without a beeper for over twenty years. In honor of this fact, I felt that I owed my long-time companion a farewell

O BEEPER! my Beeper! our fearful trip is done; Technology has passed you by, the cellular has won; My call I fear, the bells I hear, the nurses all keep calling, While follow ears the constant calls, the frequency appalling;

But O heart! heart! heart! O my tired eyes of red, Now in the drawer my Beeper lies, Fallen cold and dead.

O BEEPER! my Beeper! rise up and hear the tones; Rise up—for you the phone has rung—for you the ring-tone drones; For all the nights you've wrecked my sleep—your piercing sound still burning; For all-night call, the worried moms, their anxious voices yearning;

Here Beeper! Outmoded! Now thrown beneath my bed; It is some dream that finally, You’ve fallen cold and dead.

My Beeper does not vibrate, his transistors are still; My pager has no batteries, he has no pulse nor will; The phone is clipped on safe and sound, text messages received; With cool ring-tones, Verizon phones, will be all that I need;

Exult, I-Phone, and ring, Ma-bell! With two-year contracts wed, For in the trash my Beeper lies, Fallen cold and dead.

My apologies to Walt Whitman.