some GUIDELINES for ccs cases - ohmygod

[ArchivalUser]

--Case Management Strategies


Typically, your first step after reading the case information will be to order a physical examination. You'll need to decide whether to order a complete examination or a more limited examination. Remember that there is a "cost" to performing a complete examination, especially in the acute patient, since a complete exam takes time and it may be very inappropriate to proceed with certain irrelevant segments of the physical while your patient is unstable (e.g., performing a breast exam in a patient who is acutely unstable from a cardiopulmonary standpoint). Choose the elements of the physical that would cover every possibility on your differential diagnosis list.



NOTE: The acute-unstable patient may require therapy even before the physical exam is obtained. For instance, if the patient is hemodynamically unstable, intravenous access should be obtained even before you proceed with the physical.



At this point you should again consider your differential list and decide whether you have sufficient information to make a diagnosis and start managing the patient's disorder. Even if you are completely confident of your patient's diagnosis, it may still be very appropriate to order safe confirmatory tests. On the other hand, if you can make a diagnosis in the acute-unstable patient, then you may proceed directly to ordering appropriate therapy even before obtaining confirmatory evidence (e.g., if a patient has no breath sounds on one side and a deviated trachea, you should order a chest tube without confirming the pneumothorax with a CXR)



After completing the physical examination, it is usually time write orders. Remember that the first order of business is to ensure that the patient is stable and that you have ordered any emergent procedures first. The orders should include both diagnostic tests and any therapy that you think is appropriate at the present time.



Once you have submitted your orders (including diagnostic tests or treatments), it will usually be time to move the clock to get the orders executed and the results back. However, before advancing the clock you should also ask yourself whether the patient needs to be moved to another location, e.g., the patient who presents to your office hemodynamically unstable will need to be moved to the emergency department before you move the clock. Note: The patient doesn't go anywhere unless you move him/her there! The patient will sit in your office with massive hematemesis and bright red rectal bleeding all over your white office carpet until you decide that the patient should be transferred to the emergency department.

Now its time to move the clock. Remember that once you move the clock forward, it cannot go back. The order sheet will inform you how long it will take to get each test back. While you can click the clock option of "move clock to first result," just remember that your patient is still around and it may not be appropriate to move the clock that far ahead before you do something else that can be done immediately (e.g., give the patient pain medication). If the clock is advanced and your patient was unstable before you advanced the clock, the patient will remain untreated during that entire time interval. Therefore, before advancing the clock ask yourself whether anything needs to be done in terms of the patient's management.



Remember, when you are ordering tests they should address the (hopefully very few) choices in your differential diagnosis and allow you to choose one as the correct diagnosis. Order the simple, noninvasive, low-cost tests first and get the results back before you order second-line tests of greater sophistication, cost, and invasiveness.



The Primum ® instructions indicate that consultants should be called when appropriate. However, the program indicates that "typically, consultants are not helpful since the exam is designed to assess your patient management skills." However, do not hesitate to order the appropriate consultation when you believe that consultant's input is essential.



After obtaining any test results, ask yourself whether your differential diagnosis has changed and whether you have sufficient information to make a firm single diagnosis. If you have enough information to be confident in your diagnosis, then you should begin treating the patient appropriately. If you are already confident of the correct diagnosis, do not order unnecessary tests just to convince yourself. This only adds expense, potential risk, and loss of time, all of which may lead to a deduction of points from your score.



Once you have made your firm diagnosis and ordered treatment for the patient, it is time to examine the outcome of your treatment decisions. This will involve moving the clock forward an appropriate interval. At that point you will be told of the patient's clinical status, which may be improved, worse, or unchanged. If the patient's condition has improved but he/she is not entirely well, then you may need to order additional therapies. If the patient has improved entirely, then the next step would be choosing an appropriate interval for follow-up and moving the clock forward to that time. If the patient's clinical condition worsens after your therapy, then you must consider whether you may have the wrong diagnosis or the wrong treatment for the right diagnosis, or whether you are treating the right diagnosis with the right medication in a patient whose clinical condition is worsening nonetheless.



Once you are confident that you have chosen the right diagnosis, have treated the patient appropriately, and are told that the patient's clinical condition has improved entirely, decide whether the patient requires any further follow-up and advance the clock to that time.



At some point, at or before the maximum 20-25 minutes of real time you have to manage the case, a screen will appear that informs you that you 5 minutes left. Do not assume that an early appearance of the "End of Case" notification indicates that you have managed the patient correctly or incorrectly. On the one hand, you may have managed the patient so efficiently and effectively that the case ends well before the maximum 20-25 minutes of "real-time." On the other hand, you may have managed the patient so poorly and dangerously that the program feels that the patient (and you) is beyond salvage at this point.

When the "End of Case" screen appears, if there is "real-time" available, you will have a few minutes to consider and finalize your orders. At this point, you can add new orders, as well as cancel orders that have not already been carried out. However, if an order has already been performed, it is impossible to cancel or reverse that order; once something is done, as in real life, you cannot undo it.



Remember that your attention to "health maintenance issues" is included in the scoring algorithms. This includes appropriate counseling for your patient as well as monitoring the patient to determine the effects of treatment and to determine whether modifying your treatment regimen is appropriate.
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GL to all !
omg!

[ArchivalUser]

Very nice
Thanx

[ArchivalUser]

Thnx a lot....
very nice

[ArchivalUser]

c`mon guys dont make fun of me!

You are one of Great guys on this forum, I have to thank you for your help.
You, both , are on my Honor List of UsmnleForum members

[ArchivalUser]

Health Care Is Not A Right
by Leonard Peikoff (January 23, 1998)

Delivered at a Town Hall Meeting on the Clinton Health Plan
Red Lion Hotel, Costa Mesa CA
December 11, 1993


Good morning, ladies and gentlemen:

Most people who oppose socialized medicine do so on the grounds that it is moral and well-intentioned, but impractical; i.e., it is a noble idea -- which just somehow does not work. I do not agree that socialized medicine is moral and well-intentioned, but impractical. Of course, it is impractical -- it does not work -- but I hold that it is impractical because it is immoral. This is not a case of noble in theory but a failure in practice; it is a case of vicious in theory and therefore a disaster in practice. So I'm going to leave it to other speakers to concentrate on the practical flaws in the Clinton health plan. I want to focus on the moral issue at stake. So long as people believe that socialized medicine is a noble plan, there is no way to fight it. You cannot stop a noble plan -- not if it really is noble. The only way you can defeat it is to unmask it -- to show that it is the very opposite of noble. Then at least you have a fighting chance.

What is morality in this context? The American concept of it is officially stated in the Declaration of Independence. It upholds man's unalienable, individual rights. The term "rights," note, is a moral (not just a political) term; it tells us that a certain course of behavior is right, sanctioned, proper, a prerogative to be respected by others, not interfered with -- and that anyone who violates a man's rights is: wrong, morally wrong, unsanctioned, evil.

Now our only rights, the American viewpoint continues, are the rights to life, liberty, property, and the pursuit of happiness. That's all. According to the Founding Fathers, we are not born with a right to a trip to Disneyland, or a meal at Mcdonald's, or a kidney dialysis (nor with the 18th-century equivalent of these things). We have certain specific rights -- and only these.

Why only these? Observe that all legitimate rights have one thing in common: they are rights to action, not to rewards from other people. The American rights impose no obligations on other people, merely the negative obligation to leave you alone. The system guarantees you the chance to work for what you want -- not to be given it without effort by somebody else.

The right to life, e.g., does not mean that your neighbors have to feed and clothe you; it means you have the right to earn your food and clothes yourself, if necessary by a hard struggle, and that no one can forcibly stop your struggle for these things or steal them from you if and when you have achieved them. In other words: you have the right to act, and to keep the results of your actions, the products you make, to keep them or to trade them with others, if you wish. But you have no right to the actions or products of others, except on terms to which they voluntarily agree.

To take one more example: the right to the pursuit of happiness is precisely that: the right to the pursuit -- to a certain type of action on your part and its result -- not to any guarantee that other people will make you happy or even try to do so. Otherwise, there would be no liberty in the country: if your mere desire for something, anything, imposes a duty on other people to satisfy you, then they have no choice in their lives, no say in what they do, they have no liberty, they cannot pursue their happiness. Your "right" to happiness at their expense means that they become rightless serfs, i.e., your slaves. Your right to anything at others' expense means that they become rightless.

That is why the U.S. system defines rights as it does, strictly as the rights to action. This was the approach that made the U.S. the first truly free country in all world history -- and, soon afterwards, as a result, the greatest country in history, the richest and the most powerful. It became the most powerful because its view of rights made it the most moral. It was the country of individualism and personal independence.

Today, however, we are seeing the rise of principled immorality in this country. We are seeing a total abandonment by the intellectuals and the politicians of the moral principles on which the U.S. was founded. We are seeing the complete destruction of the concept of rights. The original American idea has been virtually wiped out, ignored as if it had never existed. The rule now is for politicians to ignore and violate men's actual rights, while arguing about a whole list of rights never dreamed of in this country's founding documents -- rights which require no earning, no effort, no action at all on the part of the recipient.

You are entitled to something, the politicians say, simply because it exists and you want or need it -- period. You are entitled to be given it by the government. Where does the government get it from? What does the government have to do to private citizens -- to their individual rights -- to their real rights -- in order to carry out the promise of showering free services on the people?

The answers are obvious. The newfangled rights wipe out real rights -- and turn the people who actually create the goods and services involved into servants of the state. The Russians tried this exact system for many decades. Unfortunately, we have not learned from their experience. Yet the meaning of socialism (this is the right name for Clinton's medical plan) is clearly evident in any field at all -- you don't need to think of health care as a special case; it is just as apparent if the government were to proclaim a universal right to food, or to a vacation, or to a haircut. I mean: a right in the new sense: not that you are free to earn these things by your own effort and trade, but that you have a moral claim to be given these things free of charge, with no action on your part, simply as handouts from a benevolent government.

How would these alleged new rights be fulfilled? Take the simplest case: you are born with a moral right to hair care, let us say, provided by a loving government free of charge to all who want or need it. What would happen under such a moral theory?

Haircuts are free, like the air we breathe, so some people show up every day for an expensive new styling, the government pays out more and more, barbers revel in their huge new incomes, and the profession starts to grow ravenously, bald men start to come in droves for free hair implantations, a school of fancy, specialized eyebrow pluckers develops -- it's all free, the government pays. The dishonest barbers are having a field day, of course -- but so are the honest ones; they are working and spending like mad, trying to give every customer his heart's desire, which is a millionaire's worth of special hair care and services -- the government starts to scream, the budget is out of control. Suddenly directives erupt: we must limit the number of barbers, we must limit the time spent on haircuts, we must limit the permissible type of hair styles; bureaucrats begin to split hairs about how many hairs a barber should be allowed to split. A new computerized office of records filled with inspectors and red tape shoots up; some barbers, it seems, are still getting too rich, they must be getting more than their fair share of the national hair, so barbers have to start applying for Certificates of Need in order to buy razors, while peer review boards are established to assess every stylist's work, both the dishonest and the overly honest alike, to make sure that no one is too bad or too good or too busy or too unbusy. Etc. In the end, there are lines of wretched customers waiting for their chance to be routinely scalped by bored, hog-tied haircutters some of whom remember dreamily the old days when somehow everything was so much better.

Do you think the situation would be improved by having hair-care cooperatives organized by the government? -- having them engage in managed competition, managed by the government, in order to buy haircut insurance from companies controlled by the government?

If this is what would happen under government-managed hair care, what else can possibly happen -- it is already starting to happen -- under the idea of health care as a right? Health care in the modern world is a complex, scientific, technological service. How can anybody be born with a right to such a thing?

Under the American system you have a right to health care if you can pay for it, i.e., if you can earn it by your own action and effort. But nobody has the right to the services of any professional individual or group simply because he wants them and desperately needs them. The very fact that he needs these services so desperately is the proof that he had better respect the freedom, the integrity, and the rights of the people who provide them.

You have a right to work, not to rob others of the fruits of their work, not to turn others into sacrificial, rightless animals laboring to fulfill your needs.

Some of you may ask here: But can people afford health care on their own? Even leaving aside the present government-inflated medical prices, the answer is: Certainly people can afford it. Where do you think the money is coming from right now to pay for it all -- where does the government get its fabled unlimited money? Government is not a productive organization; it has no source of wealth other than confiscation of the citizens' wealth, through taxation, deficit financing or the like.

But, you may say, isn't it the "rich" who are really paying the costs of medical care now -- the rich, not the broad bulk of the people? As has been proved time and again, there are not enough rich anywhere to make a dent in the government's costs; it is the vast middle class in the U.S. that is the only source of the kind of money that national programs like government health care require. A simple example of this is the fact that the Clinton Administration's new program rests squarely on the backs not of Big Business, but of small businessmen who are struggling in today's economy merely to stay alive and in existence. Under any socialized program, it is the "little people" who do most of the paying for it -- under the senseless pretext that "the people" can't afford such and such, so the government must take over. If the people of a country truly couldn't afford a certain service -- as e.g. in Somalia -- neither, for that very reason, could any government in that country afford it, either.

Some people can't afford medical care in the U.S. But they are necessarily a small minority in a free or even semi-free country. If they were the majority, the country would be an utter bankrupt and could not even think of a national medical program. As to this small minority, in a free country they have to rely solely on private, voluntary charity. Yes, charity, the kindness of the doctors or of the better off -- charity, not right, i.e. not their right to the lives or work of others. And such charity, I may say, was always forthcoming in the past in America. The advocates of Medicaid and Medicare under LBJ did not claim that the poor or old in the '60's got bad care; they claimed that it was an affront for anyone to have to depend on charity.

But the fact is: You don't abolish charity by calling it something else. If a person is getting health care for nothing, simply because he is breathing, he is still getting charity, whether or not President Clinton calls it a "right." To call it a Right when the recipient did not earn it is merely to compound the evil. It is charity still -- though now extorted by criminal tactics of force, while hiding under a dishonest name.

As with any good or service that is provided by some specific group of men, if you try to make its possession by all a right, you thereby enslave the providers of the service, wreck the service, and end up depriving the very consumers you are supposed to be helping. To call "medical care" a right will merely enslave the doctors and thus destroy the quality of medical care in this country, as socialized medicine has done around the world, wherever it has been tried, including Canada (I was born in Canada and I know a bit about that system first hand).

I would like to clarify the point about socialized medicine enslaving the doctors. Let me quote here from an article I wrote a few years ago: "Medicine: The Death of a Profession." [The Voice of Reason: Essays in Objectivist Thought, NAL Books, c 1988 by the Estate of Ayn Rand and Leonard Peikoff.]

"In medicine, above all, the mind must be left free. Medical treatment involves countless variables and options that must be taken into account, weighed, and summed up by the doctor's mind and subconscious. Your life depends on the private, inner essence of the doctor's function: it depends on the input that enters his brain, and on the processing such input receives from him. What is being thrust now into the equation? It is not only objective medical facts any longer. Today, in one form or another, the following also has to enter that brain: 'The DRG administrator [in effect, the hospital or HMO man trying to control costs] will raise hell if I operate, but the malpractice attorney will have a field day if I don't -- and my rival down the street, who heads the local PRO [Peer Review Organization], favors a CAT scan in these cases, I can't afford to antagonize him, but the CON boys disagree and they won't authorize a CAT scanner for our hospital -- and besides the FDA prohibits the drug I should be prescribing, even though it is widely used in Europe, and the IRS might not allow the patient a tax deduction for it, anyhow, and I can't get a specialist's advice because the latest Medicare rules prohibit a consultation with this diagnosis, and maybe I shouldn't even take this patient, he's so sick -- after all, some doctors are manipulating their slate of patients, they accept only the healthiest ones, so their average costs are coming in lower than mine, and it looks bad for my staff privileges.' Would you like your case to be treated this way -- by a doctor who takes into account your objective medical needs and the contradictory, unintelligible demands of some ninety different state and Federal government agencies? If you were a doctor could you comply with all of it? Could you plan or work around or deal with the unknowable? But how could you not? Those agencies are real and they are rapidly gaining total power over you and your mind and your patients. In this kind of nightmare world, if and when it takes hold fully, thought is helpless; no one can decide by rational means what to do. A doctor either obeys the loudest authority -- or he tries to sneak by unnoticed, bootlegging some good health care occasionally or, as so many are doing now, he simply gives up and quits the field."

The Clinton plan will finish off quality medicine in this country -- because it will finish off the medical profession. It will deliver doctors bound hands and feet to the mercies of the bureaucracy.

The only hope -- for the doctors, for their patients, for all of us -- is for the doctors to assert a moral principle. I mean: to assert their own personal individual rights -- their real rights in this issue -- their right to their lives, their liberty, their property, their pursuit of happiness. The Declaration of Independence applies to the medical profession too. We must reject the idea that doctors are slaves destined to serve others at the behest of the state.

I'd like to conclude with a sentence from Ayn Rand. Doctors, she wrote, are not servants of their patients. They are "traders, like everyone else in a free society, and they should bear that title proudly, considering the crucial importance of the services they offer."

The battle against the Clinton plan, in my opinion, depends on the doctors speaking out against the plan -- but not only on practical grounds -- rather, first of all, on moral grounds. The doctors must defend themselves and their own interests as a matter of solemn justice, upholding a moral principle, the first moral principle: self- preservation. If they can do it, all of us will still have a chance. I hope it is not already too late. Thank you.

-- Copies of this address in pamphlet form are available from: Americans for Free Choice in Medicine. Almost ten years ago, Leonard Peikoff predicted that our medical system would be dismantled. Looking at the young people in the crowd, he remarked:

"If you are looking for a crusade, there is none that is more idealistic or more practical. This one is devoted to protecting some of the greatest [men] in the history of this country. And it is also, literally, a matter of life and death -- -YOUR LIFE, and that of anyone you love. Don't let it go without a fight!" -- From "Medicine: The Death of a Profession" by Leonard Peikoff from concluding remarks from 1985 presentation with Dr. Michael Peikoff.

[ArchivalUser]

thanx