Monday, September 29, 2003

Older Kids More at Risk in Car Crashes

Saturday, September 27, 2003

To Sam Adams.
I'll raise a glass in salutation.
DVT and the complications thereof are in the media a lot lately. Aventis has their "killer legs" advertising campaign out in an effort to sell some Lovenox. The New England Journal of Medicine has papers about a randomized trial of d-dimer in the diagnosis of DVT, as well as a review of the evaluation of pulmonary embolus. (Sorry, full text requires subscription)
The d-dimer paper describes a trial comparing d-dimer to ultrasound in the diagnosis of DVT in outpatients. The authors report that a negative d-dimer effectively rules out DVT in outpatients. At my institution we have used the d-dimer as a method to determine the need to call out a tech to do a duplex exam. If the d-dimer was negative, the ultrasound would be done the next day. This has probably kept several good techs from leaving, as they were being called in to duplex every swollen leg. The problem is that a positive d-dimer doesn't rule in a DVT, since many other conditions can cause an elevated d-dimer (surgery, pregnancy, ect..).
The clinical practice paper is a good overview of the clinical, laboratory, and imaging studies used to evaluate a patient for pulmonary embolus. Conventional pulmonary angiography is heavily emphasized as a diagnostic test. The last pulmonary angiogram I saw was in medical school. It would be difficult to persuade a radiologist to do one today. Fortunately I have the advantage of a 16 slice helical scanner at my institution, which is very accurate in ruling a PE in or out.
Something we have started to use at my institution is a retrievable caval filter. This is attractive for use in the trauma patient. Trauma patients are at a high risk for DVT/PE both from the hypercoagulability associated with their injury, as well as prolonged immobility. While compression devices and SQ heparin can help prevent DVT, they are not perfect, and some patients (solid organ injury, early spinal injury and cerebral hemorrhage) cannot be placed on heparin. Filters have been proven to prevent pulmonary emboli in trauma patients. Because the risk of thromboembolism in trauma patients is only short-trerm, and occurs (for the most part) in young patients, permanent filters are not all that attractive. There is also the rarity of thromboembolism, as a study revealed that about 60-70 filters would have to be placed to save one life. However, while rare, a PE can be devastating. This system is deployed through a 6 french sheath, and may be removed (and replaced if neccesary) within 4-6 weeks via a percutaneous technique. This filter can be used in larger vessels (30mm) than the conventional "Greenfield" filter. This is still an off-label use. Thre are other reusable filters this is the only one that can be retrieved via a femoral approach, eliminating the risk of pneumothroax. The indications for the use of this filter may expand to make this a viable treatment alternative for the non-trauma patient.

Tuesday, September 23, 2003

Don't quite know what to make of General Clark's entry into the Democratic presidential fray, although the "stalking horse" theory seems plausible. An analysis by Brendan Miniter in today's Opinion Journal and his outlook on modern warfare reminded me of a George Will column written December 20, 1999. To quote...
...In Kosovo-actually over Kosovo--- NATO practiced a kind of warfare made possible by modern technologies and perhaps made necessary by modern sensibilities. It was a war waged on the principle that there are values important enough to fight, meaning kill, for, even if they are not important enough to die for....
Blogger has been eating my archives. Anyone else having this problem?
Read Beyond the Blame: A No-Fault Approach to Malpractice with great interest. I feel that this sort of system bears looking at. One of the best parts of it is that case would be decided by a panel of physicians and laypeople. This would help eliminate the bad outcome/complication = negligence problem that is prevelant in medical liability today.
One problem I could see is that these panels could quickly become overwhelmed by cases, unless some guidelines of what is reportable and what is not are put into place. Is a simple wound infection "reportable"? Is a pneumothorax from a central line? If the figure of 97 percent of "negligent care" cases resulted in no suit, a panel to capture those patients could be quite busy.
One of the problems with a no-fault system is cost. As this Medical Economics article points out:

Affordability, though, is a real-life issue for New Zealand's no-fault system. Outlays for patients injured by medical errors and mishaps rose 82 percent from 1997-'98 to 2001-'02. The cost per claim has been rising dramatically, and the system piles on new claims even while it continues to pay on old ones. Some New Zealanders are so concerned about the level of spending that they've proposed having physicians reimburse the government for what it pays injured patients.

And about what to report....
New Zealand's situation doesn't surprise health care economist Patricia Danzon, a professor at The Wharton School of the University of Pennsylvania. "I don't think there's an advantage in moving away from a fault-based system," she says. "It's hard to define a compensable injury if you eliminate the idea of error. You don't want to pay for all bad outcomes, but where do you draw the line? The cost can go through the roof
Something to think about?
via D.B.'s Medrants

Monday, September 22, 2003

2000 SERVED!!!
Got back from the OR and found out I have reached my 2000th visitor. Thanks to all who have made this possible.

Sunday, September 21, 2003

10 Things Your Lawyer Won't Tell You
Take a look at number nine....
"Wanna sue me? Oops — you signed that away."
Most lawyers are competent and ethical. But what if yours screws up? Can you sue him? Not if you agreed to submit disputes to arbitration, where the rules of law and evidence don't always apply, and you'll have neither the right to a jury nor perhaps even the right to appeal.

Many lawyers insert compulsory arbitration provisions in their retainer agreements, which isn't necessarily unethical, according to the ABA, providing that the agreement doesn't insulate the lawyer from liability and the client understands what it means. Such a clause should be a warning for you to take your business elsewhere.

Inventor Walter R. Fields says he didn't realize he was giving up his right to sue when he hired Maslon Edelman Borman & Brand, a large Minneapolis law firm, to sue the builder of his mold-infested $1.2 million house. Disappointed when he lost his case, Fields tried to sue Maslon Edelman for malpractice, claiming, among other things, that the firm had failed to submit evidence of the mold in time. But in 2001 a Minneapolis court refused to hear the case because of an arbitration clause in Fields's retainer agreement. Fields also came up empty after arbitrators rejected his claim and two courts upheld the arbitration. He has declined to discuss the case further until he has exhausted all possible legal remedies. Maslon Edelman denies malpractice, claiming the mold was a side issue, and defends the arbitration clause, saying that Fields had weeks to review the agreement with a lawyer before signing

Why wouldn't this work for physicians? I seem to recall an uproar over a physician's requirement that his patients signed away their right to sue before he would see them. (I've tried unsuccsessfully to find a link, anybody have one?) I think that thisis sauce for the gander myself.
via Overlawyered

Wednesday, September 17, 2003

Elderly British lady has an ambulance called for her to take her to the hospital, ten minutes away. Her son, in Spain on vacation, is also called. He arrives at the hospital BEFORE SHE DOES!!!!
Is this what we want?
The placebo effect.
via the Onion

Monday, September 15, 2003

From the Washington Post Older Women Now Surpass Young Men in Admissions. As the number of elderly rise and especially the number of elderly drivers increase, this will be more of a problem. Eldery people have worse outcomes for similar injuries than do younger patients.
This has been recognized by the American College of Surgeons in the latest update to ATLS:
Although there have not been substantial changes in the course content, there are changes to Chapter 10 (formerly Pediatric Trauma), which now is entitled "The Extremes of Age." The chapter is divided into two parts, one dealing with pediatric trauma and the other dealing with trauma in the elderly.
Even the "young" elderly have worse outcomes from traumatic injury. To paraphrase a great surgeon:
"There is nothing that brings a patient's physiological age in line with their chronological age faster than a major injury"
Review in USA Today about Edwin Black's War Against the Weak. In this book Black describes the connections between American researchers and those in Nazi Germany. To quote:
There was research collaboration and reports on the Nazi efforts in respected journals like the Journal of the American Medical Association (JAMA).
The sad history of forced sterilization in the U.S. is also mentioned. It goes without saying that the atrocities committed by the Nazis were horrible acts that should never be allowed to happen again, and that the forced sterilization of "undesirables" in the U.S. was a great injustice. But is a person without health insurance a victim of that magnitude?
Apparently the editor-in-chief of the Journal of the American Medical Association thinks so:
But DeAngelis (Catherine D. DeAngelis, MD, MPH) sees echoes of eugenics in the plight of uninsured Americans. The sense of entitlement that led the best and the brightest to call for removal of the unfit allows 40 million to go without health insurance now, she says. "We don't castrate people anymore, but by not providing them access to health care, we still mistreat the weak and the poor."
Can we compare people who were sterilized against their will, or killed, because of a disability or their ancestry, to people who don't have health insurance? Sometimes by choice? In a country where emergency care is provided to all who need it? I think that the comparison made above diminishes the injustice done to those who suffered from the advocates of eugenics over the past 100 years.

Sunday, September 14, 2003

With budget woes in both Georgia and Alabama, cuts are going to have to be made. With Medicaid taking up a good deal of both states' budgets, cuts will come from this as well. One of the favorite methods of doing this is to cut reimbursement to physicians. This is much easier than cutting back on eligibility. Why?
From a numbers standpoint, there are more consumers of medical care (and Medicare/Medicaid) than providers. Some of those consumers (the elderly) are very involved politically. Others (children, the disabled) have interest groups which do an effective job advocating for them. Politicians by their nature are not eager to offend large numbers of well-motivated voters.
Additionally, the perception of all doctors as "rich" makes reimbursement cuts more tasteful.
Another reason, in my opinion, is that the responsibility a physician feels toward their patients creates an unlevel playing field.
...More than anything, I realize, I have chosen to practice medicine to be part of my patients' lives and to treat them as thoroughly as I can. If I change this essential approach, I may jeopardize their health, not to mention my identity as a physician. True healers cannot look constantly at dollar signs.....
Insurance executives and politicians have no such qualms. Physicians were maligned in West Virginia and Pennsylvania (where the Attorney General threatened the licenses of physicians who were considering walking out). I don't think that the sentiment is wrong, it's why I do what I do. But the ideals that serve as the basis of that statement won't pay for my rent, staff salaries, or my liability insurance. Most physicians practices are small businesses, and are subject to the same forces as any small business, with the execption that we cannot pass on our cost increases to our "customers". (For additional ranting see my earlier post)
One thing that gives policy-makers pause about cutting reimbursement is that currently, participation by physicians is voluntary. If a physician makes a determination that they cannot continue to accept Medicare or Medicaid from an economic standpoint, they may opt out. This raises the possibility that if reimbursement is too low, physicians will opt out in enough numbers that access will become a problem.
"If we just saw Medicare patients and didn't see anyone with regular insurance, we wouldn't be able to pay the bills," said Dr. James E. Kurtz, an internist at Chatham Crossing Medical Center in Pittsboro, N.C. ....
Elsewhere, many doctors are refusing to see Medicare patients. "Some counties in Washington have no doctors who take new Medicare patients," Dr. Douglas Paauw, a professor of medicine at the University of Washington, said

But those in South Florida don't have that luxury.
Doctors in South Florida do not have a choice. Private insurers there pay the same as Medicare or less, and so many old people live in the area that if doctors want to practice, they must accept them. But how to make a living?
This is one problem that I have with a single-payer system of health insurance. If the government is the only game in town, without any competition, our options would be limited, and we would be at the mercy of people who have never taken the Hippocratic oath.
Thanks to DB for the links.
Congrats to the citizens of Texas in general and to GruntDoc and Dr. Rangel in particular.

Saturday, September 13, 2003

Good story of a psychiatrist who undergoes minimally invasive CABG in Opinion Journal yesterday. A good line:
Surgeons are often wrong but never uncertain.
Although it's good to be right more often than wrong.

Friday, September 12, 2003

After looking at the bill for his operation, my friend says he now understands why they wear masks in the operating room
From the Atlanta Journal-Constitution

Wednesday, September 10, 2003

I may offend some by linking to this post The Price of Fatherhood--a Father's Reply to
Ann Crittenden's 'Mothers Manifesto'
but I think that it is applicable to physicians, both mothers and fathers. While (for the most part) physicians are not endangering life or limb on the job, the sacrifices made are substantial:
While in college, we study,study study, all in order to get into medical school. Some of us worked to put ourselves through school.
While in medical school the hours increase, study, anatomy lab, ward clerkships. We have to read, prepare for tests, take call and come home tired.
As a resident, hours increase, post-call come home exhausted. Signifigant other wonders, "Why do you have to read? You're not in school anymore."
As an attending, hours don't change much. Signifigant other wonders when will it get better?
You grow apart from your signifigant other..... maybe you get divorced.
All through this you miss your children growing up, miss ballgames, recitals, plays.
I worked 60 hour, six day weeks ...... I missed my young son so badly that many times, arriving home from work late at night, I would carry him around the house on my shoulder, even though he was asleep.
As I sit in my office and look at the pictures of my children, I sometimes wonder if all this is worth it.
I'm entering one of those "self loathing" periods.
No wonder specialty choice is changing.
New York Times had an article yesterday about the advances in biopsy technology. The author touts the advances in minimally-invasive biopsies of the breast, colon, and prostate. The potential pitfalls of these techniques are examined. The big two are sampling error and insufficient tissue for diagnosis. In my practice I perform a good deal of core biopsies of the breast, either freehand, ultrasound guided, or stereotactic (mammography based). I give my patients the option of this approach or a more conventional open biopsy. I explain to them the worries over sample error and tissue quantity. I tell them if the path report doesn't jibe with everything else, an open biopsy may be needed. I explain the benefits of cosmesis and minimal discomfort. I am also able to facilitate their workup by doing the freehand or US cores in the office, same day, or can usually get time on the stereotactic table within a day or so. A free spot on the OR schedule may not be available for an open biopsy for a week or so.
One of the shortfalls of stereotactic breast biopsy is what to do with atypical ductal hyperplasia (ADH). Roughly eleven percent of biopsies with ADH have co-existing ductal carcinoma in situ. A conventional biopsy is indicated to properly diagnose these patients.
Another issue with core biopsy of the breast is that the mass is not removed. Some women have undergone core biopsy with a benign diagnosis and then return months later because the mass can still be felt and it bothers them. They want it out. So far all of my core biopsy diagnoses have been confirmed by excisional biopsy. (knock knock)
Of course doing these procedures in the office may be deadly, but more on that later.

Monday, September 08, 2003

DocShazam has an excellent post about how a life can be saved during a trauma with a simple intervention.
Shortly after I posted my comment about her post, I had the not-so-simple intervention.

Young man, restrained passenger, death of other occupant. Transferred from referral facility with cerebral contusion, orthopedic injuries, right pneumothorax with chest tube in place and "very bad pulmonary contusions". No mention of hypoxia from referring MD. Arrests twice enroute, probably from hypoxia. Arrives with BP in 90's and SaO2 in the 40's, and it's not a technical problem. CT of abd/pelvis O.K. CT of chest shows two contusions. One takes up 100% of his right lung, the other takes up 90% of his left lung. SaO2 still in 40-50's. Turn the O2 up, increase the PEEP, invert the I:E ratio.....BP falls from adverse effect on cardiac output. "Pressure falling doctor...." Robbing Peter to pay Paul my response. Give some blood, fill the tank, change out a single lumen central line for a multi lumen....turn PEEP down....SaO2 falls. Got breath sounds on both sides....belly still soft. Start the dopamine...CVP in 15-18 range. PEEP back up. Call the intensivist..."Too unstable for the oscillator.." SaO2 70's with BP in low 100's. Now in DIC.... Dopamine to 20 mcgs...
All the while in the ED I'm thinking....
I don't have an operation to save this kid...
Not many things more frustrating for a surgeon than that....
Up to the unit...More packed cells, fresh-frozen, crystalloid.... PA catheter with PAD in the 20's. No SvO2 capability... Due to the Herculean efforts of the ICU team SaO2 in the low 90's on FiO2 of 85 %, Dopamine down to 8mcgs.
In my comment I wrote....
...the "What do I do now?!?" feeling will become more infrequent.....
But it can always come back. The little voices I heard were my trauma attendings ....fluid is your friend.....A then B then C......look for a surgical problem.
There are a lot of times when trauma is no fun at all.

Sunday, September 07, 2003

Alabamians will go to the polls on Tuesday to vote on Amendment 1, which will allow a major overhaul of the tax system in Alabama. Polls show the amendment will fail by a substantial margin. This despite editorials from three leading newspapers in the state supporting the amendment. I don't live in Alabama but one television station in my area carries into Alabama, so we get to watch Alabama political ads. I have seen multiple ads against the amendment, but not one that supports it. Gov. Riley does not have the support of his party, and while the new tax system would benefit low-income voters (raising the threshold for taxes from $4,600 to $19,500) they oppose it by a large margin. Why?
In the excellent analysis by John Fund there is this telling quote :
"Black people in particular and poor people in general have always been very suspicious when somebody in Montgomery says, 'I'm going to help you,' because usually in the end we get ripped off," state Sen. Hank Sanders told the Washington Post. He and other black politicians are backing the governor's plan, but admit it's a tough sell.
Or as Michel Martin said on This Week :
"Republicans should realize they are reaping what they have sown in playing racial politics all these years,.....because some of the people who would benefit the most from restructuring the tax code just don't trust him — in part because he is a conservative Republican."
So much for the "only Nixon can go to China" cliché. That "too damn stupid" comment from the governor's policy director didn't help.
Gov Riley will probably win a courage award for this in a few years, but will probably be looking for a new job after the election....like Roy Barnes.
Finished teaching an ATLS course. ATLS is a fun course to teach, as it is one of the few courses where the students can perform procedures (chest tubes, DPL, ect..) on living models. This site has a good description of the genesis of ATLS. ATLS is not designed for trauma surgeons per se, but residents take it because it provides a structured framework for the evaluation and resuscitation of the trauma patient.
The Trauma.org site also has inital assesment scenarios (under moulage) similar to those used to test ATLS students. Kinda neat.
Nice piece in Columbia Journalism Review by Matt Welch about bloggers as the new "alternative journalism"
via Reason

Saturday, September 06, 2003

Who do I root for in this game?
My alma mater didn't look so good today either.
Looks like blogger had an episode today, as I was unable to view any blogger-based weblog until just a few minutes ago. But as Dr. Alice writes "You can't beat free". I keep telling myself that if I keep doing this long enough I'll break down and pay for something. I see all these nice Movable-Type and Sekimori sites and just drool. I would want something that would be like blogger, that would take care of hosting and design. It would have to be simple to use as my HTML skills are fairly limited.

Thursday, September 04, 2003

via Instapundit

Wednesday, September 03, 2003

While I didn't get the hits that GruntDoc received, due to my place on his blogroll my traffic has increased as well. Its nice for the healers in the blogosphere to get some recognition from the big guys.
The Bush administration is providing new regulations in how the 1986 EMTALA law is enforced. While the intentions of EMTALA were good, the regulations (like HIPPA) have been used a club in many situations. The new regulations address many of the complaints from hospitals and physicians...

The 250 yard rule
The regulations as they are now state....
"Campus means the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the HCFA regional office, to be part of the provider's campus."

Now the regulation will read as...
Hospital property means the entire main hospital campus as defined in Sec. 413.65(b) of this chapter, including the parking lot, sidewalk, and driveway, but excluding other areas or structures that are located within 250 yards of the hospital's main building but are not part of the hospital, such as physician offices, rural health centers, skilled nursing facilities, or other entities that participate separately under Medicare, or restaurants, shops, or other nonmedical facilities.

This tightens the definition of the "emergency department". The offices of Acme Surgical Corp. are in a building leased from Big Hospital and well within the 250 yard limit. I am unsure what our obligation is currently, but the exception seems to be more clear cut.

Covering multiple hospitals
In keeping with traditional practices of "community call," physicians will be permitted to be on call simultaneously at more than one hospital, and to schedule elective surgery or other medical procedures during on-call times.

I can't find where the law specifically prohibits taking call at one or more hospitals or doing elective cases while on call. I have always done this and have been on call at one or more hospitals in the past. I think this came from the "reasonable time" provision in the regulations, but I may be wrong. It is an unfair demand that one cannot do elective cases while on call, and economically unfeasable.

Call coverage
Clarification of the circumstances in which physicians, particularly specialty physicians, must serve on hospital medical staff "on-call" lists. Under the revised regulations, hospitals will have discretion to develop their on-call lists in a way that best meets the needs of their communities.

This is not likely to make hospitals happy...

.....But Dr. Robert A. Bitterman, an emergency physician at the Carolinas Medical Center in Charlotte, N.C., said: "The new rule could aggravate an existing problem. Specialists are not accepting on-call duties as frequently as we would like. As a result, hospital emergency departments lack coverage for various specialties like neurosurgery, orthopedics and ophthalmology. The new rule could make it more difficult for patients to get timely access to those specialists.".....

Why? Because the medical staff at each hospital sets the call requirements of each department. Hospital administrators have used EMTALA as a method of forcing physicians to take unassigned call in the ED. If the regulations do not mandate 24/7 coverage hospitals are going to have difficulty in providing call coverage in the ED. The uninsured ED patient is viewed by many as a lawsuit waiting to happen. Some hospitals have begun to pay physicians to be on call, and this trend is likely to spread.
The regulations are due out next week, going into effect in November. As much dry reading is involved with the Federal Register I'll give them a look next week. This site has alot of good information about EMTALA.

Dear friend,
Leader) who was killed in the Struggle between Liberian soldiers arm forces and
his Lurds rebels on July 2003 I am currently residing in one of the European
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l does not meet your approval, please keep my confident and disregard this mail.
I look forward to your quick response.

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