Monday, February 28, 2005

Send The Whirlybird II....
From The New York Times:Crashes Start Debate on Safety of Sky Ambulances:
On a mild afternoon last week, emergency workers raced up to Jana Austin's rural Arkansas home to ask if a medical helicopter could land on her property to transport a victim of a car crash to a nearby hospital. Ms. Austin, a nursing student, said she readily agreed. But moments after the helicopter took off, she and her 4-year-old daughter stood stunned, watching as the helicopter began to spin, slowly at first, then faster, until it twirled out of control into a nearby pasture. The patient died, and the three crew members were seriously hurt.

The accident, whose cause is under investigation, was hardly isolated. In January, a medical helicopter plunged into the Potomac River in Washington, killing the pilot and a paramedic. In less than two months this year, four people have died in four accidents. Last year was a particularly deadly one for flight crews and patients, with 18 people killed in 11 accidents, the highest number of deaths in a year in more than a decade, according to federal regulators and an industry group.
As expansion baseball has diluted the talent pool in pitching, the same may be said of air ambulance pilots, and their helicopters:
The spike is putting a spotlight on a little-regulated and fast-growing sector of health care: the medical helicopter industry. There are an estimated 700 medical helicopters operating nationally, about twice the number flying a decade ago.....
......Federal regulators and some doctors worry that the pool of skilled helicopter pilots has become drained and that some of those flying are making poor decisions. In addition, some companies are flying older helicopters that lack the instruments needed to help pilots navigate safely. Of the 27 fatal medical helicopter accidents that occurred between 1998 and 2004, 21 were at night and often in bad weather, according to federal statistics.
The air ambulance industry is certainly more entrepreneurial:
Medical helicopters were once nearly all affiliated with hospitals. But more generous federal reimbursements and changes in payment methods have attracted more operators, including publicly traded corporations and smaller concerns that in some cases set up outposts and market their services to rural emergency units and even homeowners.......
....Another significant area of industry growth involves companies that are not connected to hospitals but instead set up helicopter bases in rural areas and then market their services to local hospitals, emergency officials and, at times, homeowners.

For example, Air Evac Lifeteam, which started 20 years ago with a single base in West Plains, Mo., now has 43 sites in 10 central states. For $50 a household, homeowners receive a company membership guaranteeing that Air Evac Lifeteam will not seek additional payment from them beyond what an insurer will pay. Over 150,000 households are signed up, Air Evac executives said.
There is a vigorous debate as to the utility of helicopter ambulances. A Dr. Bledsoe is quoted in the article, the same Dr. Bledsoe who was lead author of this Journal of Trauma paper from June 2004:Medical Helicopter Accidents in the United States: A 10-Year Review. :
Results: There were 84 medical helicopter accidents involving 260 persons (passengers, patients, crew, and pilots) during the 10-year study period. Of these, there were 72 fatalities and 64 injuries. The incidence of fatalities was 0.86 fatalities per accident. The incidence of nonfatal injuries was 0.76 per accident. Fifty-two percent of all reported accidents occurred during the last 3 years of the study period (2000-2002).

Conclusion: There was a steady and marked increase in the number of medical helicopter accidents in the United States during the 10-year period (1993-2002). These findings are worrisome in light of recent research that has indicated use of medical helicopters may be excessive and nonbeneficial for most patients.(emphasis mine)
Further papers from The Journal of Trauma may be found here and here.
Now as the article points out, the increase in collisions may be related to the absolute increase of helicopters in the air and the "incidence per passenger mile" may be stable. The industry will begin to monitor that in the spring. Certainly air ambulances have their roles in rural areas with bad roads. Sometimes patients may require care that only a air-ambulance crew can provide. Your county EMS may only have one or two ambulances and can't afford to lose capacity transporting patients to a faraway referral center. Helicopters are sexy and cool as well.
(As an aside it was always a coup when you could discharge a flown-in trauma from the ED. Even funnier when the patient would ask when the helicopter would arrive to take them back home.)
In my opinion the crash described above was for a trip of dubious value:
Local emergency officials said that the Arkansas car-crash victim, Robert Arneson, 71 of Harlingen, Tex., had a gash on his forehead but was stable and alert when taken by ambulance to a field for helicopter transfer.

It was about 20 air miles, or a seven-minute flight, from the crash site, a trip that would have taken about 45 minutes by ground. But because emergency workers had to locate a landing site, nearly an hour elapsed, officials said, after the first emergency call and before the helicopter took off.
So this patient could have been at the hospital, alive, with time to spare before the helicopter even took off.

Friday, February 25, 2005

It's Not a Good Day when Your Afternoon Makes the AP.....
Which is what happened to me on Wednesday. From the Atlanta Journal-Constitution:Columbus man kills his two children, then kills himself:
COLUMBUS — A father fatally stabbed his two young children, wounded three other children and then killed himself by slitting his throat after a domestic dispute Wednesday in a neighborhood of south Columbus, police said.

Clarence Lacey Moore used a hunting knife to kill 1-year-old Clarence Smith Moore, who died on the floor beside his bed from a laceration to the throat, Muscogee County Coroner James Dunnavant told the Columbus Ledger-Enquirer.

Stephan Smith Moore, 2, died in the emergency room at The Medical Center about two hours later from stab wounds to his head, neck and back, Dunnavant said.

Moore, 24, died in surgery shortly afterward.

The other three children underwent surgery at The Medical Center, hospital spokeswoman Marion Scott. Shawn Smith, 3, and Shelton Smith, 5, remained in critical condition Thursday morning, hospital spokesman Kory Lundberg said. Shelby Smith, 7, was upgraded to satisfactory condition, Lundberg said.

Beverly Moore, the mother of all the children, was not injured, Columbus police Maj. Russell Traino said.

Witnesses told police that the woman, followed by the 5-year-old with blood on her, ran screaming from a home on Benning Road, then collapsed.

"She wanted to know where her babies were at," Teresa Williams, a resident of the Baker Village housing project who helped the woman, told the newspaper.

Wednesday night, the white cinderblock house in south Columbus was quiet.

Two doors away, the words "God is Love" were featured on the billboard of the South Columbus United Methodist Church.

Nathaniel Carter, a security guard in the church parking lot, said that earlier in the day, the house was surrounded by crime scene tape and hordes of news media and police.

The pastor, the Rev. Joseph Roberson, told the newspaper that he was inside the church when the incident happened. He said he went with Beverly Moore to the hospital, and spent about four hours with her.

"She was asking, 'How could this happen?'" Roberson said. "What has me crying and hurting is those children they cannot have their lives returned."

Neighbors said the family moved to Columbus from Michigan and had lived in the house since January.

This won't be the usual "Tales From the Trauma Service" with detailed descriptions of injuries, radiographs or pictures. Given that the names of the patients are out there I think that would be crossing the line as far as confidentiality goes. If more details are put forth, I will fill in the blanks.
I was helping out a gynecologist friend of mine answer the age old question: Is it appendicitis or PID? I won, he lost. As I helped him free up the TOA the ED called up with a "trauma alert". Several children in cardiac arrest. Bidding farewell I went down to the ED. Four children with penetrating injury, unknown number in full arrest.
First child arrives, followed shortly by another. The first had an obvious evisceration but was awake and otherwise stable. I left the ED physician and nurses to start lines and draw blood.
The second child arrived, in full arrest. My partner and I assist with this until two more children arrive. An intraosseus needle is placed and my partner performs a cutdown. The child arrives in aystole and remained that way despite multiple rounds of ACLS drugs. Once it becomes clear that this child has nothing surgically correctable my partner takes child #1 to the OR. Shortly thereafter we call the code on this child.
Third child arrives. Unresponsive but with a good femoral pulse. Secure the airway. Multiple superficial lacerations but some deeper punctures to the thorax and abdomen. I start a femoral line giving fluid and blood. Get a CXR and this child goes to the OR with my other partner.
Fourth child arrives shortly thereafter the third. Responds only to pain. Stab wound to the left parasternal area. Intubated and peripheral lines started. Tremendous amount of bloody drainage in NGT. Left chest tube inserted.
Just after the first child goes to the OR, the father arrives, having slit his own throat. Was in PEA enroute but became asysolic shortly before arrival. Looks like he cut both the carotid and jugular veins on that side. Pupils were fixed and dilated. After he gets worked on awhile with no results he is pronounced. At this time I take the last child to the OR with a thoracic surgeon for exploration.
Time from arrival of the first patient to last to the OR, about 45 minutes.
Before I went to the OR I stopped and spoke to the mother. I told her that three of her children were in the operating room, and one had died. Someone behind me told me that one child had died at the scene. She became inconsolable.
It was truly like a bad episode of "ER" with shouting and lots of people working furiously to save these children's lives. Paramedics carrying limp bodies of bloodied children into the trauma bay. Then going outside to cry, vomit, or both. Nurses and house staff running these patients to the OR, then themselves breaking through the brittle shell holding their emotions in check.
As for myself, I could not comprehend what could drive someone to do this. How sick or evil this person was to do this to innocent and helpless children. What psychological price will these little ones pay for the rest of their lives?
As I was rounding one them today one told me, "I was bad."
"No ____, you have been very good throughout all this. And you will get better"
So far, my brittle shell is only cracked.

Wednesday, February 23, 2005

Vioxx and Health Insurance....
From Holman Jenkins' column in today's Wall Street Journal:Good Drug, Bad Customers - IIIn which Mr. Jenkins examines the winners and losers in what many predict is inevitable: the return of Vioxx to the marketplace:
If Merck returns the drug to the marketplace, big winners will be patients, who'd at least have an option restored to them. Doctors would have reason to be gratified too. They've gotten off lightly in the Vioxx controversy. Vioxx was a useful drug, but also a grossly misprescribed one. That's a financial judgment as much as a medical judgment. At $2 a pill, Vioxx did nothing for millions of patients that a generic, nonprescription 15-cent pill wouldn't do.

The big loser would be the insurance industry. Its attitude toward prescription drugs is "we don't want to pay for them" unless they save money by reducing the need for expensive hospital visits. Prescription drugs for mild chronic pain don't readily fit this description. Vioxx appealed mainly because it cut the risk of tummy bleeding compared to cheaper pain relievers, but even so it was a hard sell to insurers. For every patient who avoided a trip to the emergency room, insurers could expect to buy about $30,000 worth of Vioxx, and that's assuming the drug was cleverly restricted to patients at high risk for bleeding ulcers.
And an interesting fact:
So how come insurers spent $5.6 billion on Cox-2s in 2003, with 65% going to patients at low risk for tummy bleeding? More damning still, a University of Maryland study found that the more generous a patient's insurance, the more likely he was to be taking a Cox-2 -- and the less likely he was to need it. For the patients with the best coverage, in fact, there was basically zero correlation to need.
And more:
On this topic, GM's ever-rising health spending has become everyone's favorite case study, with endless repetitions of its claim to spend $1,400 per car on health care for its employees and retirees. Never mind that this figure is virtually impossible to distill useful meaning from. GM's spending per car on health care is right in line with private health care's share of the total economy -- about 8%.

Instead, the relevant questions are: Why does GM buy health care directly for its workers, when it doesn't buy their food, housing or beer? Answer: a tax incentive for companies to pay their employees in-kind in health care.

And: Does this lead auto workers to allocate a bigger share of their incomes to health care than they would if they were allocating the dollars directly? Yes, for reasons economists long ago consecrated with the phrase "tragedy of the commons." (Look it up.)

The sad truth is that neither doctors nor insurers nor GM are prepared to sacrifice a huge tax benefit for "health insurance" even while they whimper about the consequences and beg government to do something about it. We use quotation marks around "health insurance" because what insurers are selling these days is not true insurance but a mechanism to launder medical consumption through a third-party payment mill to qualify for a tax benefit.
(Emphasis mine)
How much could be saved if health insurance was used like other forms of insurance, a protection against unforeseen risk? Would you buy Vioxx (or Prevacid) instead of Tylenol or Motrin (or OTC Pepcid) if you had to pay the whole cost out-of-pocket?
Peer Review: Friend or Foe????
From Medical Economics:Is peer review worth saving?
Of the following statements, which best describes hospital peer review?

It's an impartial means of identifying and dealing with errant physicians.
It has been transformed into a weapon that enables established physicians and hospital administrators to dispatch mavericks, whistleblowers, rivals, and other nonconformists.

Your answer might depend on whether or not you're a hospital insider. Like other supercharged topics, such as malpractice litigation and tort reform, hospital peer review rarely elicits a neutral shrug from members of the medical community.
To some peer review is a blunt tool to maintain the party line:
"In the 30 years that I've been a health law attorney," says Kern, "I've never seen anyone who admits a lot of patients and is well-liked have a problem with the hospital disciplinary mechanism. On the other hand, if you're competing with such a doctor, especially if you're new to the hospital or on the wrong side of hospital politics, you're a potential target."
So is peer review the hammer to beat down the nail that sticks out?
Not only is the peer review process corrupt, it's ineffective, says Ralph M. Bard, a physician turned attorney in Tullahoma, TN. "To Err Is Human, the Institute of Medicine's report on patient safety, was released after HCQIA and the NPDB had been in place for many years. Yet the report shows a high rate of medical errors—and that error rate remains high. Rather than being used to weed out bad doctors, peer review as it exists today is used primarily as a weapon against young, vulnerable practitioners."

Peer review wasn't intended as a means to oust qualified physicians to the benefit of their more economically successful competitors, says James Lewis Griffith Sr., a malpractice attorney in Philadelphia. "Too often, however, the golden rule applies: He who has the gold makes the rules."
Woe betide the "whistleblower":
Conversely, attempts to initiate the peer review process against well-connected physicians can be hazardous to one's career, says Mary H. Johnson of Asheboro, NC. Johnson, a pediatrician and former National Health Service Corps provider, asserts that she was fired from her hospital job after filing a peer review report on a colleague who had badly mismanaged a newborn's care. "The abuse of peer review for economic reasons or to perpetuate a cover-up is medicine's dirtiest little secret," Johnson says.
But according to some, peer review does not go far enough:
"Most medical staffs aren't aggressive on these subjects," says Philadelphia attorney Alice G. Gosfield. "Physicians judging their colleagues are very concerned about the potential impact of peer review, so they'll go through all kinds of contortions to avoid taking action. So, when physicians or administrators move forward, it's usually justifiable.

"A peer review is an emotionally devastating event for a physician," Gosfield continues. "As badly as physicians handle malpractice cases, it's far worse to be criticized by colleagues with respect to professional performance. Sometimes reviews do stem from clinical judgment differences or personality issues. In my experience, they're rarely motivated by economic competition."
As a method of policing, peer review is felt to be ineffective at best:
In fact, peer review and other quality assurance efforts are so inadequate, says a malpractice claims specialist who requested anonymity, that more bad doctors are identified by insurance companies after claims are filed than are identified by their peers. "Hospital-based peer review is an ineffective way of dealing with bad doctors or questionable medical care. Physicians are more likely to be sheltered by peer review than to have it used as a weapon against them."
Some recommendations to improve the process:
Many observers who say that the peer review system is broken contend that the process needs, above all, to be made more objective. "If we're going to conduct peer review," says Linda Peeno, "an outside body should do it." This is difficult in small communities, where everyone knows everyone else, but one way to surmount that problem is to form reciprocal agreements with neighboring communities: We'll review your cases and you can review ours. Or a specialty board can hear the case
Outside review is key in avoiding the appearance of a conflict of interest on the part of the reviewers. Stories like this could be avoided.
Peer review is a necessary evil in today's world. I have served on peer review committees in the past and it is unpleasant to call one's colleagues onto the carpet, even when it is richly deserved. Currently under Georgia law peer review is non-discoverable in a civil action. This permits frank discussion of the matter at hand without having it used as fodder in the courtroom. But my friends south of the border may be hesitant to participate in peer review in the near future:
That shield has begun to crack, however. In November the Florida electorate endorsed a constitutional amendment—touted as a patient-safety measure—that would eliminate confidentiality from the peer review process. In response, the AMA, at its interim House of Delegates meeting in December voted to seek federal legislation to prohibit discovery of records, information, and documents obtained during the course of professional peer review proceedings.
Given all this, it's not surprising that physicians have to be brought kicking and screaming into peer review, on both sides of the table.

Tuesday, February 22, 2005

In response...
As a lead-in to Grand Rounds XXII Dr. Wilde puts forth a post describing the crises facing the current health care system, and some solutions:Health Care Problems and Solutions. Dr. Wilde discusses problems with health insurance, liability, drug approval, and the topic Mr. McBride took me to task for: board certification and physician licensure:
Licensing and monopoly privilege have harmed the growth of medicine as a field, lowered the quality of care patients receive, and degraded the working environment for many health care professionals. The primary economic effect of licensing is to artificially limit the supply of a good. There are less physicians practicing medicine than would be without licensing. Though such measures are usually justified for safety reasons, there is no reason licensing cannot be supplied privately as it is in other fields. Greater openness would allow different approaches to medical care to compete with each other, result in a more adequate supply of house staff, and produce better overall patient care.
The utility of government licensure for physicians was a subject of one of the first posts of this blog. I had been waiting to re-post it in anticipation of Mr. McBride getting around to what was going to be part IV in his Paternalism in Medicine series. The post was an email I had sent libertarian talk show host Neal Boortz, in reply to this portion of his program notes for July 3, 2003:
Inform your representatives that you want to be free to make your own consumer choices, and that includes choices of which professional you want to use for medical and legal services. Tell them that you are perfectly willing to rely on your own judgment, or the judgment of private accrediting agencies when it comes to selecting an attorney or a doctor. You might add that you don't like the idea that you have to go to the government to ask who may and who may not clip your fingernails.
To which I replied:
I have also heard you mention on your program that you do not feel that physicians should be licensed by the state. I am a licensed physician in the state of Georgia and I must tell you that I disagree with you on this issue.
Let us compare a medical license with the most common license issued by the state, a driver's license. To obtain a driver's license one must pass a test on the rules of the road and pass a driving test. This is done to insure a basic level of competency before one is allowed to possibly endanger one's self and others behind the wheel of a car. To obtain my license to practice medicine I had to provide documentation of my education and training. This was to insure that I had at least gone to medical school and done additional training before I could possibly endanger some poor soul
who had become my patient. This is also to insure a basic level of compentency. By requiring licensure, the state fulfills a duty to protect the citizenry against potential harm. In the paragraph above you advocate the use of private agencies to
monitor and provide accreditation of physicians. The danger in this is that, as the cliché states, "Who watches the watchers?". Physicians have the choice to submit to further examination in their field of specialty and become "board certified". Board certification is not required for licensure or for admitting and treating patients in some hospitals. If private agencies are responsible for accrediting physicians then a group of physicians can get together and form a new board or "private agency" who will then sign off on them, even if they cannot become certified by an established specialty board. You can see the potential danger this brings up.
But what about the judgment of the individual? Medicine is very complex and if a physician states he is "certified by the xyz board of specialists" the patient may accept that as adequate. At the least a patient would have to do some research to determine if that is a legitimate accrediting board, or something thrown together by some physicians of dubious credentials. By requiring licensure the state also provides accountability. A physician must meet certain requirements to maintain a license. Patient's may complain to the Board of Medicine and an investigation may be initiated. The physician may have his license revoked or put on probation. A
"private agency" may be reluctant to discipline one of its' own (dues-paying) members, and if it did, what would stop the physician from starting up his own "Board of abc specialists"? The civil litigation system would not be a good policeman either, as the physician in question could simply operate without insurance. This would remove the "deep pocket" of the liability underwriter, making the financial benefit of a case minimal.
I agree that some of the professions that require licensure and their boards are a method to limit competition (real estate agents and funeral directors come to mind), but professions that require specialized expertise (physicians, dentists, plumbers, and yes even lawyers) licensure is a method to insure a basic level of education and compentency.
So while the system is not perfect, it beats the alternative of caveat emptor.
Gramd Rounds XXII....
Hosted by Mr. McBride at Catallarchy.

Monday, February 21, 2005

The Future of Surgery X....
Two articles from this months and last month's General Surgery News. First off: Are Changes in Trauma Specialty Spinning It Toward a Crash?
It's March 1979, and you're a senior surgery resident. You've just spent 30 straight hours at the hospital, mostly in the OR working on one case after another, including a hepatic lobectomy on a woman who was shot in a domestic violence incident and a splenectomy on a car crash victim.

You're tired, you wouldn't mind seeing your wife and kids at least once this week and you really need a place to lie down, but you've got six more hours to go. The first patient waiting for you is a kid with a stab wound in his abdomen. Still, you count your blessings for the umpteenth time that you've decided to pursue this line of work. You're every inch the "master surgeon," having operated on every part of the body, with some vascular and orthopedic surgery thrown in for good measure. If only the legendary Dr. Red Duke were in town to see you work.

Fast forward 25 years to a senior resident today. You're leaving the hospital after a 24-hour stint, ready to go home for a nap before taking your family to your parents' place for the traditional Sunday night supper date. As chief resident, you've had the usual string of cases, including many CTs and a few focused abdominal sonograms for trauma (FASTs) on patients who fell or were in car crashes. It's been several shifts since you've seen a serious gunshot or stabbing victim. You'd like to stay and help the attending with an exploratory laparotomy case left over after he took call with you last night, but it's simply against the rules. You're starting to get really worried about him, actually: he is distressed over the number of cases being foisted on him. You're thinking for the 10th time this week that you should have heeded your medical school friends' advice and forgone trauma surgery for something with much better pay and hours, like bariatrics or colorectal surgery.
The advances in trauma surgery have greatly changed how it is practiced:
"When I was growing up, we did lots of gunshot wounds, stabbings, all kinds of trauma cases," said H. David Reines, MD, vice chair, Department of Surgery, Inova Fairfax Hospital, Falls Church, Va. "The hours were horrendous, divorce rates were terrible, but it was exciting: you spent your life in the hospital taking care of folks. And you didn't care if you got paid or not because you were on salary. Plus, no one was too worried about malpractice. It was fun and everybody did everything."

The advent of peritoneal lavage and a decrease in violent crime leading to fewer penetrating injuries, along with other major developments in the nonoperative management of trauma cases, have put a new face on critical care surgery.

These changes have been so dramatic, and the culture of medicine has changed so much in recent years, that time appears to have nearly run out on the survival of the traditional trauma surgeon.

"We have this new thing where trauma centers don't make money, people want to go home at night, we don't operate very much, no one wants to take trauma call at night, and no one's reimbursing us for all the uninsured," Dr. Reines said. "The majority of the time, the trauma surgeon is babysitting. Most of my residents want to operate; they don't want to babysit."

A paper last year documented that more than 80% of trauma admissions are for blunt injuries, and that residents have to care for an average of 500 blunt trauma patients before getting to do a splenectomy or liver repair (Fakhry et al. J Trauma 2003;54:1-8).
Those numbers are such that many directors of trauma programs may not be operating enough. There are also issues with reimbursement, specialty coverage, and liability concerns that make trauma surgery unattractive as a career for residents.
In an attempt to increase reimbursement and to increase operative experience some academic trauma departments have expanded in to "trauma and emergency surgery" programs. From this month's issue:Saving a Specialty: Does the Acute Care Service Sweeten or Sour the Deal for Trauma Surgery? :
Trauma centers around the country are trying to solve the crisis besetting today's trauma surgeons. The most common way is by creating an acute care service or emergency general surgery service, in the attempt to significantly increase both operative volume and revenue for trauma surgeons and their institutions.

In fact, emergency general surgery, which encompasses emergency trauma surgery, general surgery and critical care, has become so popular nationwide that a joint ad hoc committee of the American Association for the Surgery of Trauma (AAST) and the American College of Surgeons' Committee on Trauma is considering it as a potential subspecialty, an approach that has the makings of being a good fit for the academic, financial and lifestyle needs of the younger generations, and may subsequently attract future attendings and residents alike.

However, the success of acute care surgery services---and hence the enthusiasm with which trauma surgeons are embracing them---varies widely among regions and between hospitals.

"The concept of an emergency surgical hospitalist is anathema to those of us over 40, but may be the reality for the future. It's the only way to maintain our surgical skills," observed H. David Reines, MD, vice chair, Department of Surgery, Inova Fairfax Hospital, Falls Church, Va., where the creation of a full-time trauma service is being evaluated. "But the workload will be tremendous, and I think the most dangerous aspect is that the colorectal surgeons, the vascular surgeons, the orthopedic surgeons and the neurosurgeons aren't going to feel like they have to do trauma surgery. They of course prefer to see patients and operate during the day."
Several different models have been tried from the all-inclusive:
At the Denver Health Medical Center's Rocky Mountain Regional Trauma Center, which in 1979 created one of the first acute care surgery services in the country, six full-time trauma surgeons manage all of the institution's general, noncardiac thoracic and vascular surgical trauma cases, as well as all critical care, nontrauma emergency, urgent and elective surgery cases. Trauma and critical care call is divided equally between the six members of the team.

Fully 41% of the 4,082 cases performed by the acute care surgery service members from 2002 to 2003 were elective, according to a review presented by David Ciesla, MD, assistant professor of surgery at Rocky Mountain, at the AAST 2004 annual meeting. Another 40% were urgent cases and 11% were emergencies. Only 332 cases (8%) were trauma operations. Among the nonelective operations, 53% were abdominal or alimentary procedures, 22% were vascular, 14% were thoracic and 9% were head and neck cases. Moreover, while the trauma cases tended to come into the hospital on weekends, other emergency surgery cases were spread evenly throughout the week, with urgent cases usually cropping up before 6:00 p.m. on weekdays.

"Our data have shown that in this environment, trauma surgeons can provide high-quality thoracic and vascular operative care," Dr. Ciesla said. "The broad range of operative procedures managed by our service is facilitated by not having to actively compete for cases with specialty services. This is a solid first step towards reclaiming the trauma surgeon's operative potential."

He added that they are considering tacking on the emergency procedures of specialty services such as neurosurgery, including placement of intracranial pressure monitors and performing decompressive craniotomies.
To the more limited:
In yet another model, surgeons at the Vanderbilt University Medical Center in Nashville created a separate, nontrauma, emergency general surgery service in 2000. At their institution, surgeons perform both emergency and elective general surgery, also exclusive of vascular or other emergencies now outside the purview of most general surgeons. There is one surgeon dedicated to all emergency department surgeries 24 hours a day, with seven attendings staffing the emergency surgery and trauma services. A chief resident-run team of residents and a number of physician extenders, such as acute care nurse practitioners, lend support to the surgeons.
The Denver model would be difficult to achieve at most places nowadays because of increasing specialst creep keeps residents from being skilled at procedures outside the realm of general surgery. But while the operative experience may be increasing, it's not very satisfying:
The analyses by Virginia Commonwealth and Vanderbilt also indicate that adopting an emergency general surgery service means that surgeons not only perform a greater number of the more "desirable" operations but also take on a growing proportion of the unglamourous tasks, such as drainage of perirectal or intra-abdominal abscesses, as well as other "pitfalls," like routine appendectomies and cholecystectomies, according to Dr. Reines and other opinion leaders in the field.

"Initial enthusiasm for the solution of adding nontrauma emergency surgery responsibilities has the potential to be short-lived, because the majority of these surgical emergencies consist of draining soft-tissue infections and excising necrotic gastrointestinal structures," said Denver's Dr. Ciesla. "Indeed, it can be argued that coverage of these surgical emergencies has a greater effect on the job satisfaction of the somnolent elective surgeon---whether he be a general surgeon or a subspecialist---who is relieved of these responsibilities."(emphasis mine)
Of course this comes as no surprise since the "somnolent general surgeon" doesn't take trauma call anyway, so why should he shed a tear over losing the butt puss at night?
The attendings have had to absorb the majority of the blow, as the 80-hour workweek shelters the residents. Attendings now work an average of 87 hours a week and have about five in-house calls monthly, with a sixth night backing up a fellow. Each of the in-house calls averages 34 hours when surgeons are on service, and at least 26 hours when they are not.

"When you look at this, and present this to a resident and say, 'How would you like to work more hours than your residents, operate a lot postcall, work on your postcall day, have your academic time consumed doing elective cases instead of pursuing research interests or traveling to meetings? Doesn't that sound like a good career to you?' they'd say, 'Not a chance!'" said Lewis Kaplan, MD, director of Yale's Surgical Emergencies service, after presenting the information at the AAST's 2004 annual meeting. "I'm not sure this is really the model we wish to pursue in order to attract residents and keep trauma surgery alive."
So the "emergency/trauma surgery" concept can cut both ways. It can increase surgical volume and income for the trauma surgeon, or it can make the "kick me" sign on the surgeon's back even larger.


Mammography Tool.....
From CNN:Stats: Mammogram would cut deaths by third:
If every woman aged between 50 and 79 got a mammogram every year, it would reduce deaths from breast cancer by 37 percent, according to a new statistical tool.

Screening these women every two years would reduce mortality by 30 percent, Sandra Lee and colleagues at Harvard Medical School and the Dana Farber Cancer Institute in Boston calculated.
They would like to put their algorithm on the internet to allow women to weigh their risk about brest cancer.
"Health policy makers can use this information to come up with public screening (recommendations)," Lee told a news conference at the annual meeting of the American Association for the Advancement of Science.

"An individual woman can use this to decide what is better for her. A 7 percent reduction may not be so big for some women. It may be important for other women."
The current recommendations are not uniform:
The American Cancer Society recommends that women 40 and older have a mammogram every year. The National Cancer Institute also recommends starting at 40 and having one every one or two years.

But the British National Health Service offers mammograms only after 50 and at three-year intervals, while other European countries often offer them every two years.
The American Association for the Advancement of Science has not put the text of the speech or copy of the paper on their website so I have no idea how they came to the 37% reduction in deaths from cancer. Moving along:
"It's clear that the more mammograms you give, the more able you are to locate disease that a person didn't know about," Zelen said in a statement.
Yes, but would that correspond to an increased survival?
But more tests can lead to detection of non-cancerous lumps that must be biopsied, costing money and anxiety.

Lee said her model was not meant to provide an absolute guide to whether more screening is better.

"Breast cancer in a woman in her 40s is more aggressive, so it would make sense to have frequent screening," she said -- even though breast cancer is more rare in this age group.

And because breast cancer is more common in women over 50, it could also be argued that frequent screening benefits this group, she said.
Breast tissue is also more dense in younger patients, which reduces the effectiveness of mammography. Which is one reason mammograms are not offered to thirty year-olds.
There are also more benefits to having mammograms than just saving lives, said Dr. Timothy Rebbeck of the University of Pennsylvania School of Medicine.

"To the degree that you can identify tumors earlier, you can be saving some costs," he told the news conference. Women can have a smaller surgical procedure and perhaps escape the need for chemotherapy and radiation.
Now we are beginning to compare apples and oranges here. The accepted indications for chemotherapy have expanded over the years to the point where a premenopausal woman with a tumor of 1cm or larger is going to be offered treatment. The threshold for post-mastectomy radiation has been lowered as well. So while the disease may be detected earlier, the therapy may still be aggressive.

Thursday, February 17, 2005

Euthanasia in Massachusetts....
From National Review Online and The Boston Globe:Hospital plans to remove patient from life support despite wishes of family:
Massachusetts General Hospital said it plans to remove a 79-year-old patient from life support next week, against the wishes of the woman's family and despite a court ruling that said her daughter had the right to decide when to pull the plug.

Barbara Howe has advanced-stage amyotrophic lateral sclerosis, often referred to as Lou Gehrig's disease, an incurable and degenerative muscle disease. She has been in a hospital bed on a ventilator since 1997. She cannot speak and can barely move, but remains mentally alert, her daughter, Carol Carvitt, told the Boston Herald.

"Her face lights up when you talk to her," Carvitt said. "I visit her four times a week, and my sister visits her every single day. You can see the eye move back and forth and her mouth starts moving."

MGH doctors wanted to remove Howe from her breathing machine last year because they said she was suffering and would not want to be kept alive. But a Probate and Family Care judge ruled that Carvitt should be allowed to determine her mother's future care.

"I evaluate every day what is in her best interest," Carvitt said.

Dr. Britain Nicholson, the hospital's chief medical officer, said on Wednesday that he ordered Howe taken off life support next Wednesday because her condition has worsened.

"Our hospital's position is Mrs. Howe's condition has continued to deteriorate to the point that it needed to be readdressed," and that it is "in Mrs. Howe's best interest to discontinue life support."

Nicholson informed Carvitt of the hospital's position with a phone call and a letter earlier this month.

"I'm devastated and I'm angry," Carvitt said. "Devastated because they're trying to terminate my mother's life. And angry because they're violating a court order."

The probate judge last week declined to issue a restraining order against the hospital, but Carvitt's lawyer, Gary Zalkin, said the judge left open the option for them to renew their motion for a restraining order after receiving additional information from the hospital.
No Terry Schiavo-type family dispute here, the family seems to be united in this. Dr. Nicholson does not dispute (in the article) that Mrs. Howe is unresponsive.
I have no problem with the withholding of aggressive or invasive therapies to patients that would not benefit from them or change the eventual outcome, despite family wishes I also believe that families can and should make decisions about the withdrawal of care.
Has the Groningen Protocol" found a home in the U.S.?
Are Specialty Boards Monopolistic????
The answer would be "yes" according to a physician quoted in this New York Times article:Vascular Surgeons Bang on the Specialists' Door
He would seem an unlikely radical, but Dr. Frank J. Veith is waging an aggressive and unusually public fight in the clubby world of the medical profession.

A 73-year-old vascular surgeon who is the vice chairman of surgery at Montefiore Medical Center, in the Bronx, Dr. Veith is on a crusade aimed at the way the medical establishment divides its turf among different specialists. He and his supporters want to have vascular surgeons, doctors who operate on blood vessels, officially recognized as board-certified specialists.

Surgeons like Dr. Veith argue that this designation would improve patient care by ensuring that doctors who repair aortic aneurysms or perform other vascular surgeries are trained in that specialty. But those who oppose creation of the independent medical board that would oversee and certify that specialty say Dr. Veith and his backers are engaged in a power grab that would only fragment the field of surgery.

Dr Veith takes the view of that the recent proposal to streamline vascular training with a primary certificate as a first step since this plan does not call for the establishment of a separate board.
A separate board already exists but they want the recognition of the American Board of Medical Specialties.
The article quotes many for and against the concept of a separate vascular surgery board. Some highlights:
Some doctors say a new vascular board is unnecessary because vascular surgeons are already awarded a subspecialty certificate through the American Board of Surgery. "We're not particularly interested in giving that up," said Dr. Lewis, whose group includes other specialists like pediatric surgeons.

Those subspecialty certificates do not prevent general surgeons from performing vascular surgery, and he acknowledged that doctors who do higher volumes of a procedure tend to have better results.

And hospitals can already require doctors who perform vascular surgery to have subspecialty certification, Dr. Lewis said. "An independent board is not going to change that one iota."......
...But the vascular surgeons strenuously disagree, arguing that some of the training in vascular surgery that is now part of the general surgical education is being wasted on generalists who they say are either unlikely to ever again perform such operations or who may fool themselves into thinking they can handle complicated cases.

But what caught my eye was this quote from Dr. David Meltzer from the university of Chicago:
"Physicians are a bunch of monopolists who control entry into their profession in all sorts of ways," said Dr. David O. Meltzer, a physician and economist at the University of Chicago.

While medical specialization frequently leads to better care, he said, doctors are also eager to try to keep others from treating their patients for the same ailments.
If this is true, is it a bad thing? Should we let any Tom, Dick, or Harriet perform any procedures they wish? The public already is critical of our ability to police ourselves and at the same time when we try to improve the quality of our product we are attacked as "monopolists". Does Dr. Meltzer disagree with state licensure? Granted, board certification is a rather blunt tool for determining how a particular physician's patients will fare, but it is often the only one that we have. Volume of individual and institution are much better indicators of outcome. And there's not some big mystery about becoming board certified. You graduate from a accredited medical school, attend an accredited residency, submit data about your training (such as the number and type of cases performed) and sit for a test (or two). You don't have to know the secret knock or handshake and you don't have to wait for someone to retire or die before you can get in.
And despite the portrayal of Dr. Veith as a David against the ABMS Goliath, Dr. Veith is a monopolist himself, a vice-chair who won't write letters for his own residents in support of them obtaining vascular privileges. I personally have no problem with the creation of such a board, but as I have written before the results will take years to mainifest:
(T)here is no national body which determines what procedures a surgeon may or may not perform. Each individual hospital sets their own standards for privileges. Some hospitals require fellowship training and/or certification, while others may not (the same may be said for managed care organizations). Smaller or rural hospitals may not initiate a requirement for board certification.
Secondly, any changes, after they were initiated, would take several years to show the effects desired. That is because the "grandfathering" that would occur. Even the most vocal proponents of the creation of a new board agree that would have to occur...

Dr. Veith will find out the results in about a month.

Wednesday, February 16, 2005

Georgia Tort Reform Update III....
Happy days are here again. From the Atlanta Journal-Constitution:Jury award limits OK'd
In an abrupt about-face, the state Senate approved legislation Monday to overhaul Georgia's civil justice system that was hailed by medical and business lobbies and condemned by trial lawyers and consumer advocates.

On Thursday, the Senate fell one vote short of approving the bill approved only moments earlier by the House to set limits on damages in medical malpractice lawsuits. But after a weekend of intense lobbying, the Senate voted 38-15 in favor of the bill.

"There's been a pent-up demand for comprehensive civil justice reform," Senate President Pro Tem Eric Johnson (R-Savannah) said after the vote. "When push came to shove, it was time to make it happen. I don't think anybody wanted to extend the emotional debate over this issue any longer."

Senate Bill 3 imposes a cap of $350,000 — or up to $1.05 million in multidefendant cases — on jury awards for malpractice victims' pain and suffering.

The legislation also will make it extremely difficult for a victim of malpractice to win damages, including lost wages and medical bills, for injuries caused by negligence in an emergency room procedure.

The bill's sponsors expect Gov. Sonny Perdue to sign it into law, but a spokeswoman for the governor said no signing date has been scheduled. Perdue will conduct a "thorough and deliberate review" of the legislation, Heather Hedrick said.

On Thursday, nine Republicans in the Senate voted against the bill, even though the Republican leadership has made overhauling civil justice a top priority this session. On Monday, the nine Republicans switched and voted for the bill. Four Democrats also changed their minds and voted in favor.

The bill's chief sponsor in the Senate, Preston Smith (R-Rome), called the legislation a reasonable compromise. "The bill is the right thing for us to do today," he said during debate Monday.
For the lack of one vote Friday, the bill had to come back. The following does not inspire confidence in our elected officials:
Another Republican, Sen. John Douglas of Covington, said he had initially voted against the bill by mistake. He said he was away from his desk, discussing highway projects, when he found out there was a roll call vote on SB 3. When he returned, he said, he saw some Republican colleagues voting against it and he joined them.

"I thought I'd missed something," said Douglas, a retired military officer. He acknowledged if he had been more aware, the vote Monday would not have been necessary.
And what about standing on principle?
Sen. Seth Harp (R-Midland), who gave an impassioned speech against the bill last week, voted for it Monday because, he said, he was certain it would pass.

"I can count," Harp said. "I was beat, plain and simple. . . . There's no point in riding a dead horse."
In the end the caps were not the most controversial issue, but the burden of proof in ER cases:
One provision bitterly opposed by some lawmakers would allow medical malpractice victims in emergency room cases to prevail in court only after proving by clear and convincing evidence that an ER health care provider committed "gross negligence."

It was signed today by Governor Perdue at an Atlanta hospital:
Calling it “a great bill for Georgia,” Gov. Sonny Perdue signed into law Wednesday legislation that will cap pain and suffering awards in medical malpractice lawsuits at $350,000, or up to $1.05 million in multidefendant cases. It was the first bill signed into law this session.

At a signing ceremony at the Women’s Center at Northside Hospital, the governor said Georgia was on the verge of a crisis with doctor’s leaving the profession because the cost of malpractice insurance.

“This is about access to health care,” he said. ” I’m here today at this wonderful women’s center

The law also will make it difficult for a victim of malpractice to win damages, including lost wages and medical bills, for injuries caused by negligence in an emergency room procedure.

Doctors and hospitals say the legislation was needed to hold down exorbitant malpractice insurance premiums that are forcing physicians to leave Georgia or stop practicing.

The full text of the law may be found here.

Tuesday, February 15, 2005

Now Old Enough to Drink....
Grand Rounds XXI at Sumer's Radiology Site.
Bariatric Surgery Follies II....
The title for "most comments in a post" easily belongs to this one in which I comment on a WSJ article about a "mini" gastric bypass. It seems I was linked by a discussion board on bariatric surgery as the comments were mainly testimonials from Dr. Rutledge's patients. Well it seems that one of the master's pupils has gone to the "dark side". From CNN:Hospital sued over wrong surgeries
A doctor may have performed the wrong type of gastric bypass surgery on more than 50 patients at a Wilmington hospital, officials said.

Dr. Steven E. Olchowski performed the surgeries between December 2000 and the spring of 2002 at New Hanover Regional Medical Center, which is facing eight malpractice lawsuits stemming from the weight-loss operations.

"We cannot be sure about any conversation in Dr. Olchowski's office between him and his patients," Dr. Samuel Spicer, vice president of medical affairs at New Hanover Regional, said Wednesday.

The lawsuits claim Olchowski told patients he would perform a gastric bypass surgery known as Roux-en-Y, which usually is covered by health insurance. According to the lawsuits, he performed minigastric bypass, which usually is not covered.

The difference between the surgeries is how the stomach and intestines are attached.

Attorneys for six of the patients said their clients had serious complications such as stomach ulcers and required a second surgery to convert the bypass into a Roux-en-Y.

It wasn't immediately clear how much the lawsuits sought in compensation.

Olchowski, 57, resigned from New Hanover Regional in 2003. He now practices at Ionia County Memorial Hospital in Michigan.

He did not return a call Wednesday to the Star-News of Wilmington.

I'm sure he will face some investigation for insurance fraud as well.
I await the flood of testimonials from Dr. Olchowski's patients....
And We're Back..
Very busy two weeks has brought about a paucity of posts. It started soon after I hosted Grand Rounds I had to take this young man back to the OR for re-exploration for an intra-abdominal abscess. He had several return trips with an open abdomen and was closed with absorbable mesh about 10 days ago. He was discharged to rehab today. Taking him back on my birthday and throwing the monkey wrench into Mrs. Parker's plans didn't help much.
Then I had to prepare for a talk I gave last Monday. During those preparations my hard drive gave it up with the loss of some data. I spent the latter part of last week sorting that out.
I was on call over the weekend and was beaten like the proverbial baby seal, so no time for posting.
Since yesterday was Valentine's day posting from home last night was verboten.
As these two weeks went by I found that earlier in the "hiatus" I didn't miss posting all that much. But as the time past and the big project (the talk) was completed, I began to curse the obstacles that got in between myself and ACTCIACTC. I guess I'm fully addicted now.

Wednesday, February 02, 2005

State of the Medical Union....
To make our economy stronger and more productive, we must make health care more affordable, and give families greater access to good coverage, and more control over their health decisions. I ask Congress to move forward on a comprehensive health care agenda — with tax credits to help low-income workers buy insurance, a community health center in every poor county, improved information technology to prevent medical errors and needless costs, association health plans for small businesses and their employees, expanded health savings accounts, and medical liability reform that will reduce health care costs, and make sure patients have the doctors and care they need.

We'll see what happens....
Georgia Tort Reform Update II...
From the Atlanta Journal Constitution: Senate OKs bill to reduce malpractice suits, cap awards
After hours of emotional testimonials and pointed name calling, a bitterly divided Senate on Tuesday approved legislation designed to reduce malpractice lawsuits against doctors and hospitals.

The 39-15 vote came shortly after MAG Mutual Insurance Co., which insures most of Georgia's doctors, agreed to roll back premiums by 10 percent if the legislation is signed into law and upheld on appeal. Such a rollback would amount to an annual premium savings of $20 million for insured Georgia physicians, the company said

Sen. Preston Smith votes yes on a version of Senate Bill 3 while talking to Sen. Steve Thompson. Smith sponsored the bill meant to reduce malpractice lawsuits, but Thompson opposed it. The tort reform bill now goes to the House.

A top GOP priority this session, tort reform now moves to the House, where Republicans are in the majority and expected to approve their own bill. House Majority Leader Jerry Keen (R-St. Simons Island) said Monday he will push for swift passage.

Senate Bill 3 includes a fiercely debated cap on jury awards for a malpractice victim's pain and suffering — beyond economic damages for medical bills and lost wages. The health care industry has said the cap is necessary to hold down insurance premiums. Consumer rights activists and trial lawyers countered that caps will prevent malpractice victims from being justly compensated and discourage lawyers from taking the cases.

Senate Judiciary Committee chairman Preston Smith (R-Rome), the lead sponsor of the legislation, said access to health care has become a crisis across the state. He noted there are no neurosurgeons on call from Macon to Jacksonville and that many obstetrician-gynecologists have stopped delivering babies as a result of rising insurance premiums.

In an ideal world, juries would be allowed to award malpractice victims as much as they deserve, Smith told his colleagues. "But it may not in practical reality work if we're losing access to health care in this state."
Glad to see that MAG mutual put their money where their mouth is.
As usual such debates can become emotional:
In a halting speech to his colleagues, Sen. Judson Hill (R-Marietta) said he knows firsthand what it's like to be a victim of a doctor's malpractice.

Often pausing to choke back tears, Hill recounted how his wife, pregnant with twin boys in December 1988, went into premature labor that he said should have been halted. She delivered the boys, but they died as he cradled them in his arms, Hill said.

"All too well, I know who has suffered at the hands of doctors," Hill said. "And I hope I'm the only one in this body who has such a tragic story."

Even so, Hill said medical malpractice reform is "desperately needed."

"Frivolous and wasteful lawsuits are literally choking our businesses to death," he said. Hill urged his colleagues to consider those who might die because some communities no longer have emergency rooms to treat them.

"We will not hear from people who died because there was no hospital nearby," he said.
The key provisions:

Cap jury awards for "noneconomic" damages — those for a victim's pain and suffering — at $250,000, or up to $750,000 if multiple defendants are held liable.The biggest benefit, according to some.

Encourage out-of-court settlements by making some parties pay their opponent's court costs and attorneys' fees if they could have settled the case early on but did not.The opposition has 30 days to respond. If they do not respond or decline and the award is less than 125% of the original offer, the side that declined the offer would be liable for attorney's fees.

Require extensive court hearings to determine what kind of expert testimony is allowed at trial.Mandates pre-trial hearing of expert testimony.

Allows juries to consider the wage-earning potential of nonworking spouses and infants who are victimized by medical malpractice. Fair since one objection to "non-economic" caps has been that these groups are discriminated against.

Require doctors to report to the Composite State Board of Medical Examiners any judgment or settlement involving allegations of malpractice. The board also must assess a doctor's license to practice if the doctor has been disciplined three times in the past 10 years. This would be stricter than the current system. The CSBME now only requires settlements of over $100,000 to be reported.

Discourage lawyers from venue shopping to get jury pools more favorable to plaintiffs.

Require juries to precisely apportion damage awards in multidefendant casesA much needed reform of the "joint-and-several liability" law.

In addition there is an "apology provision":
The General Assembly finds that conduct, statements, or activity constituting voluntary offers of assistance or expressions of benevolence, regret, mistake, error, sympathy, or apology between or among parties or potential parties to a civil action should be encouraged and should not be considered an admission of liability. The General Assembly further finds that such conduct, statements, or activity should be particularly encouraged between health care providers and patients experiencing an unanticipated outcome resulting from their medical care. Regulatory and accreditation agencies are in some instances requiring health care providers to discuss the outcomes of their medical care and treatment with their patients, including unanticipated outcomes, and studies have shown such discussions foster improved communications and respect between provider and patient, promote quicker recovery by the patient, and reduce the incidence of claims and lawsuits arising out of such unanticipated outcomes. The General Assembly therefore concludes certain steps should be taken to promote such conduct, statements, or activity by limiting their admissibility in civil actions.

The exemptions for emergency treatment were removed but could be a part of the house bill.
The full text of the bill may be found here.

Tuesday, February 01, 2005

Pop goes the Aorta...
From today's New York Times:Aneurysm Tests Urged in Older Men Who Smoked
In a sharp change from current policy, an influential medical advisory group is recommending that all men ages 65 to 75 who have ever smoked have an ultrasound screening test to see if they are developing a condition that could kill them in minutes by bursting a major artery in the abdomen.

The group, the United States Preventive Services Task Force, is an independent panel of medical experts that advises the federal Agency for Healthcare Research and Quality. Its recommendations help set government policy and are generally followed by primary care doctors.

The task force last looked at the condition, abdominal aortic aneurysms, in 1996 and concluded that there was insufficient evidence that a screening test would save lives. But now, it said, four large clinical trials have provided the evidence it needs, at least for those most at risk.
Recommendations such as this have been going around in the vascular literature for quite awhile. The screening is needed because many patients with aneurysms do not know they have one. During my residency I operated on about 20-30 ruptured aneurysms. How many were aware of the condition? None. Zero. Surprise, surprise.
The condition kills at least 9,000 people a year in the United States. With screening, "the science comes down to saying this is worth doing," said Dr. Ned Calonge, chairman of the task force and chief medical officer of the Colorado Department of Public Health and Environment.....The recommendation affects about 9.8 million Americans, the 70 percent of the nation's 14 million men ages 65 to 75 who are smokers or have ever smoked. The task force defined the group to include any man who had smoked at least 100 cigarettes in his life......The task force estimated that for every 500 men who meet its criteria and are screened, one death would be prevented over five years. In comparison, the only test for colorectal cancer that was evaluated in a randomized controlled trial, the fecal occult blood test, requires that 1,374 people be screened to prevent one death over five years.

While the number affected is large, the criteria are fairly strict:
The task force limited its recommendations to men aged 65 to 75 who have smoked because rupture is rare in people under age 65 and is at least three times as likely in people who have smoked. The condition is about four times as common in men as in women. Anyone with a family member who had an aneurysm is at increased risk. High blood pressure is a more minor contributor to risk and cholesterol does not seem to make much difference, researchers say.
After 75, the life expectancy is considered too short and the operation too risky.
The "operation too risky" argument against screening older people hopefully will diminish in importance as endovascular methods become refined.
Is it Time-Released for Long-Lasting Relief????
Grand Rounds XIX at Daily Capsules
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