Wednesday, November 30, 2005

I read this post on The Well Timed Period and found the logic lacking.

ema, if having an abortion is so much safer than carrying a pregnancy to term, do you counsel your pregnant patients to get abortions? Do you advise them of the 1000% increase in relative risk to which you refer in this post?

BTW, the link you provided for this astonishing statistic is just a statement without any link to real stats to support it. Is this in the US, or do these numbers come primarily from the developing world? What about New Hampshire?

You quoted the New Hampshire Medical Society and asked the question: “Is the standard of care for a patient with a serious health condition to have to wait until her health status becomes near death?” To what “serious health condition” are you referring? How common is this condition in a teenage girl? The law does provide for judicial consent if the girl cannot/will not discuss her pregnancy and medical conditions with her parents.

Your comment “According to New Hampshire legislators…if the patient is female” is a little ridiculous. Why bring gender into a discussion of pregnancy? There is no comparable condition in males. Are you suggesting that the legislators in New Hampshire are such sexists that they would only apply this law to females? Name one medical condition, short of immediate threat to life or limb, where a physician would not be required to obtain consent from a parent for a boy or a girl. As I wrote here, in the ER I can't even give a Tylenol without parental consent.

Besides, this law doesn’t require consent, only notification. Name any surgical procedure other than abortion where a physician is not required to seek parental consent, again, aside from immediate threat to life or limb, for an unemancipated minor.

You state, “And just to be clear, receiving adequate care after an abortion is independentof parental involvement; it’s the standard of care.” Tell me, if you are called to the ER to evaluate a 13 year old girl with a severe post-abortion complication requiring hospitalization or surgery, are you going to proceed without parental consent. I don’t know what state you are in, but in Tennessee, we wouldn’t.

If you saw a 14 year old girl in the ER with abdominal pain and fever, 6 hours after an abortion, with free air on the x-ray, would you take her to the OR without talking to her parents? I doubt it.

I don’t disagree that allowing a minor to consent to carrying a pregnancy to term and not allowing her to consent to an abortion is inconsistent.

You bring up HIPAA. Notifying a parent of treatment of a minor is not a violation of HIPAA, as any physician should know. Aside from your comments regarding a pregnant minor carrying a pregnancy to term, what medical issues would you not discuss with a 13 year old's mother?

How many abortions a year are provided “to protect the health of the mother?” Ignore the fact that if this is her first pregnancy, she isn’t a mother. This argument is always brought up in discussions of abortion. You state, “…until, their health deteriorates to the point where the only options left are treatment or death.” How often does this happen? Again, we’re discussing a generally very healthy patient population. To what conditions are you referring?

Would you take issue with a law that simply stated, "Any physician must seek parental consent prior to providing medical services, other than life/limb saving, to any minor?" This would apply equally to boys and girls.
The elected legislature in New Hampshire has passed a law requiring "parental notification" and a 48 hour waiting period before a minor could get an abortion. Pro-abortion advocates are up in arms and have sued, claiming the law doesn't provide for exceptions to protect the health of the mother.
The New Hampshire case is being closely watched by the dozens of states that require minors to tell a parent or get permission before having an abortion.

Justices were told that 24 states mandate a parent's approval and 19 states, including New Hampshire, demand parental notice.

The court is considering whether the 2003 New Hampshire law puts an "undue burden" on a woman in choosing to end a pregnancy. O'Connor is an architect of the undue burden standard, and was the deciding vote in the last abortion case five years ago, when justices ruled that a Nebraska law banning a type of late-term abortion was too burdensome.

That law, like the one at issue Wednesday, did not have an exception to protect the mother's health. New Hampshire argues that exceptions are permitted when the mother's health is at risk, and that should be enough.

The law requires a parent or guardian be notified when an abortion is planned for someone under 18, followed by a 48-hour waiting period. A judge can waive the requirement.

"In an emergency, a woman needs to go to the hospital not a courthouse," justices were told in a filing by Jennifer Dalven, attorney for Planned Parenthood of Northern New England which challenged the law.
Without specific comment on the subject of abortion, I would like to discuss the concept of abortions to save the life of the mother and the concept of emergency care.

I am at a loss to imagine a scenario whereby a normal intrauterine pregnancy is dangerous to the life of the mother or an emergency scenario involving a normal intrauterine pregnancy that would be treated with an abortion.

In today's world of emergency medicine, if a minor presents for medical care with a life threatening condition, she would be treated even if the guardian could not be reached. In the ED, we are careful to get, at a minimum, phone consent before treating non-life threatening things, but if a minor presented in extremis with a ruptured appy, for example, she would be given the appropriate life saving treatment.

I can't imagine any "emergency" condition of pregnancy that would be treated with an abortion, anyway. What are the "emergency" conditions of pregnancy, anyway? Uterine rupture, ectopic, abruption, hemorrhage, for example. None of these are treated with abortion.

So, if we cannot identify an "emergency" condition of pregnancy that would be treated with an abortion and no "life-threatening" condition of pregnancy that could not wait for parental notification, what's the problem?

The abortion advocates just don't want any restrictions on abortion at all. What's so special about abortion, anyway?

The abortion advocates object to spousal notification before an abortion, because "it's the woman's body to do with as she wishes." So telling a man that his pregnant wife is about to abort his child violates her right to privacy. If the objection to parental notification is that this violates the child's right to privacy, where does this right come from? Where does this right end?

Again, what so special about abortion, anyway? Name any other surgical procedure where a physician isn't required to get parental consent. Heck, I can't prescribe antibiotics for strep throat or give Tylenol to a minor for a headache without parental consent. This law doesn't even require parental consent, just parental notification.

Perhaps New Hampshire should just state that any physician/medical provider that wishes to provide medical services/treatment to a minor must obtain parental consent, unless there is a reasonable opinion that the delay would result in irreparable harm to the minor.

Above, I quoted Jennifer Alven stating, "In an emergency, a woman needs to go to the hospital not a courthouse," Referring to the option of judicial consent, as opposed to parental notification. In an emergency, there is not requirement to present to a courthouse. As an ER doc, I would call the judge on the phone and get consent to treat that way. Meanwhile, it is my understanding that presentation to an ER with a life-threatening condition is implied consent to treat, at least to stabilize the emergency condition.

If anyone out there can identify an emergency condition of pregnancy for which an abortion is therapeutic, please let me know. I'm not talking about induction and delivery, like for a severe abruption, but an abortion, as it is commonly considered.

Tuesday, November 29, 2005

Hat Tip to DrHelen for a pointer to this article:
Men are being demonized in the media for a long time now. I think probably this is just society's reaction -- they think, 'We'd better start tightening up on everything.' It's getting to the stage when all men are viewed with distrust," he said.

Monday, November 28, 2005

That Karl Rove, what will he think of next?
An interesting question from Bard Parker.

I started teaching ACLS in 1990. It wasn't until 1992 that it became "kindler and gentler." As many of remember, you actually had to lead the megacode yourself and there was a possibility that your "patient" would die. The megacodes were more difficult for the docs than for the EMT's, to be sure.

However, only the docs were required to pass for their jobs and many of the non-physician participants would fail. They would often return at another class just to retest the portion they had failed.

In 1998, I was told by the course director that I was too hard on the class DURING THE LECTURE and that I would not be needed during the megacode testing!

Nowadays, you are right, it is expected that everyone will pass. Teaching ACLS is a money-maker for the institution and you want the students to recommend your classes. The last few times I taught, I was given the test before my lecture so I could, basically, tell the students what the questions were from my subject area. I have seen instructors teaching with the test in their hands.

Given the emphasis that everyone pass and the evidence that a drug company can buy its way onto an algorithm, I think ACLS is a big waste of time. It is ridiculous that a physician will complete a residency in EM and pass the boards and the hospital will require an ACLS card in order to be on the ER schedule.

Sunday, November 27, 2005

As a resident, I was taught to be careful in my prescribing habits. Be careful not to prescribe too many meds to one patient; be careful not to prescribe a med to treat the side effect of another med unless the first med was critical; attempt to stop one med for each new med started. We all know that the risk of adverse reactions or drug-drug interactions increases greatly if more than 5 meds are used.

As an ER doc and a hospitalist, I often see patients who are on greater than 10 meds. When I look at the lists, I frequently see redundant meds or contraindicated combinations. It is not uncommon to see meds used to treat symptoms created by other meds.

Unfortunately, I can't do much about it. Sometimes I can call the PMD and, gently, suggest alternative regimens, but it is difficult, almost impossible, to educate the patient directly. The patient has only just met me and his PMD has been treating him for years. Of course the PMD knows better, right?

Here in Tennessee, we have seen that our TennCare population uses a far greater number of prescription meds than in any other state. Many of those patients have now been dropped from TennCare and many of the remaining beneficiaries have been limited to 5 prescriptions a month. Of those 5, only 2 can be trade-name. This includes short term prescriptions. So a prescription for two or three days of a pain med may mean no coverage for a chronic drug.

Not that this is so bad. It requires the physician and the patient to manage the patient's regimen more specifically. In the ER, when I write a prescription for an analgesic, I can write for something inexpensive and recommend to the patient that they pay for it themselves, as opposed to using TennCare.

Here is a story about a doc trying to do the right thing.
Dr. Jei Martin is Moore's doctor. Martin says when Moore first came in her office she was on 34 medications all paid for by TennCare. Dr. Martin says she needs a blood thinner to prevent a stroke, but not 34 or even 17 prescriptions.

“I think the whole system failed in that respect the whole system failed,” said Dr. Martin.

Dr. Martin says the system failed taxpayers, and it failed Jennifer Moore, who was clearly overmedicated. Dr. Martin was reducing Moore's medications slowly. Then TennCare cuts sped things up.
FDA restricts use of Glaxo's Advair
The U.S. Food and Drug Administration had directed that drugmaker GlaxoSmithKline's biggest selling asthmatic drug Advair should be made available to asthmatics only as a last resort.
This isn't good. It is a good product and frequently a life-saver.
Hospital Cleared of Wrongdoing in Malpractice Suit
A Cameron County jury Tuesday decided that Valley Regional Medical Center was not responsible for giving an 11-year-old girl cerebral palsy during her June 1994 delivery.

The family of Krystal Galvan claimed that their daughter received the neurological and muscular disorder after hospital staff waited too long to give her mother a caesarian section.

Attorneys for the Galvan family argued that the girl suffered significant brain damage due to a lack of oxygen during her mother’s hour-long wait for the surgical procedure.

After two weeks of hearing testimony in the 107th state District Court, the eight-man, four-woman jury decided in a few hours of deliberation that the hospital was not responsible for giving Galvan the lifelong medical condition.
Johns Hopkins University To Launch Nanotechnology Program
A $1 million grant from the Howard Hughes Medical Institute, announced today, will help create a new graduate training program in Nanotechnology for Biology and Medicine at The Johns Hopkins University. The NBMed program will provide interdisciplinary training in nanotechnology and biology to a new generation of graduate students from three schools within Johns Hopkins. The goal is to provide a broader range of knowledge and skills to people embarking on careers in biology and medicine. Drawing from doctoral students in nine departments in the schools of Engineering, Arts and Sciences, and Medicine, the program is designed to help researchers acquire expertise in more than one academic area, giving them the tools needed to develop new biomaterials, drug delivery systems, biosensors and diagnostic devices.
If I were earlier in my career, I would love something like this.
Gastric pacemaker for weight loss:
The experimental device - which is called an implantable gastric stimulator - is a small battery-operated electrical generator about the size of pocket watch that is surgically implanted in the abdomen. 2 wires connect it to the stomach wall.

In a similar way that a pacemaker sends electrical impulses to the heart, the experimental gastric pacemaker gives a small current to the stomach through 4 electrodes on the wires. The electrical current is activated, adjusted or monitored by a handheld computer in the doctor's office that communicates to the pacemaker through a radio signal. (Patients typically don't feel anything during gastric stimulation, according to the company.)

It is unclear how the electrical current works. It might cause the stomach to relax and signal a feeling of fullness. It could inhibit stomach hormones that normally increase appetite. Or it may send a satiety message to the brain.
Why does our jury system hold companies liable for producing completely legal products that, when used in an inappropriate manner, result in injury or death?
Crash verdict shows need for tort reform

Ford Motor Company builds a sport utility vehicle - the Explorer - that is particularly prone to rollover accidents.

This should come as no surprise, as virtually all SUVs are rollover threats. They tend to be taller for their width and length than standard passenger vehicles, and ride higher off the ground. Hence, they're more top-heavy than a sedan or sports car and when they get sideways, sometimes just a little bit, they have a tendency to tumble.

Such vehicles even come with warnings, usually in the owner's manual and often on stickers affixed in noticeable places inside the vehicle, for a daily reminder to drive carefully and pay particular heed to the rollover risk.

So a jury verdict in Miami Monday isn't as much an incrimination of Ford for building a bad vehicle as it is an indictment of an American legal system that lets juries dole out massive punishments - and let's not forget lucrative paydays for trial lawyers - when something goes wrong and someone gets hurt or killed using a legal product.

The jury in this case awarded $61 million to the mother of a 17-year-old boy killed in an Explorer rollover: That's $1.2 million in actual damages and $60 million in pain and suffering for the boy - who is not here to spend it - and his mother.

If Ford built a truly defective vehicle that didn't meet federal safety standards or in some other way caused the death of this young man through no fault of the operators, such a financial punishment might be merited. But Lance Crossman Hall died in a 1997 traffic accident not just because the Explorer can be tipsy when swerving, but because his friend and the driver of the vehicle, Melahn Parker, fell asleep at the wheel.

Parker, who was charged with reckless driving, awoke and tried to regain control of the Explorer. But a “handling problem” caused the SUV in her care to turn sideways and roll over.

The fault in this accident begins with a young motorist asleep at the wheel and ends with a tragic fatality. A contributing factor was the type of vehicle being driven - which probably could just as easily have been a Chevy Blazer or Isuzu Trooper or almost any other SUV.

Does that make Ford primarily liable for Lance Crossman's death? Not at all, certainly not to the tune of $61 million.

This case had a more tragic ending, and thus asks more important questions and is a more worthy court candidate, than the infamous lawsuits filed by those who pour hot coffee in their own laps or who eat themselves into obesity. But the end result in this game of my lawyer vs. yours all too often is the same: Massive financial awards by juries to individuals (or their victims) who first shirked their own responsibilities.

Like staying awake at the wheel.

Saturday, November 12, 2005

I am working today as a hospitalist. About 8 days ago, I was working in the ER and saw Mr. Jones. (Name changed to protect...well, me, I guess.) He complained of abdominal pain, nausea and vomiting, and constipation.

His abdominal CT showed a huge fecal impaction in the left lower quadrant. He also had a hemoglobin of 6. For those of you in Rio Linda, that's very low.

No significant past medical history and no current medications. No significant use of NSAID's or alcohol. No complaint related to GI bleeding.

Anyway, admitted to the hospitalist service and transfused. Became hypotensive while receiving an enema and transferred to the ICU. Elevated cardiac enzymes led to the diagnosis of NSTSE MI.

Ended up being diagnosed with chronic kidney disease with acute renal failure and some renal tubular acidosis. Refused endoscopy. Refused cardiac cath.

As I was discharging him today, we were talking about future care. I wanted to share with you what he told me:
You know what, Doc? I am 4 months short of 80 years old. About 5 years ago, I was sitting on the driveway with my brother. I was sitting cross-legged on the concrete. I arose without any particular difficulty and my brother said, "Boy, I hope I am as healthy as you are when I am your age."

I told him that I probably had 5 or 6 serious things wrong with me that I didn't know about. After all, I was pretty old and those things happen as you get old. Now I'm finding out about them.

I have an incredibly good life. I have had great jobs. And I've got this wonderful red-head right here. [gestured to his wife] I don't have any regrets. Sure, there were a few bad points, but no big deals. I certainly wouldn't change anything.

I guess it's just time for me to deal with the medical problems. I'm ready.


I was amazed that his wife was able to keep from crying. I almost did. She just reached out and stroked his face.

It is not that unusual for patients in their late 70's and older to say that they are just done. Ready to go.

So many people are searching for the key to aging and ways to extend life. For a while, in the latter half of the 1900's, medical science made great strides in extending the average life expectancy of Americans. This was done mainly by preventing the death of middle-agers. They then lived for 10-20 years with severe medical diseases that would have killed them 50 years earlier. But they don't live into their 80's and up.

The people that now live to be 80's and up are the same people that would have had long lives 50 years ago. They just aren't that sick. They live to see the things they are used to go by the wayside, their friends (and often, their children) have died and they just get...I guess tired and bored is a way to say it. As Mr. Jones said, "I'm just done."

Friday, November 11, 2005

Holy Cow!!

No Way!!
Serbs line up for testicle shocks

Men in Serbia are lining up to have electric shocks delivered to their testicles as part of a new contraceptive treatment.

Serbian fertility expert Dr Sava Bojovic, who runs one of the clinics offering the service, said the small electric shock makes men temporarily infertile by stunning their sperm into a state of immobility.

He said: "We attach electrodes to either side of the testicles and send low electricity currents flowing through them.

"This stuns the sperm, effectively putting them to sleep for up to 10 days, which means couples can have sex without fear of getting pregnant.

"The method does not kill the sperm permanently and it does not affect the patient's health."

Dr Bojovic added patients were now lining up at his fertility clinic in Novi Banovci for the shock treatment, as it had none of the problems attached to using condoms, the male pill or having a vasectomy.

He added: "We are hoping to have a small battery powered version on sale in the shops in time for Xmas."
Now, I can see a potential conflict between this and this.

Monday, November 07, 2005

Some good comments on this post.

Remember, I work as a hospitalist as well as in the ER. I am in a position to feel the pain of both sides.

One of the hospitalists commented that he was worried that "things would be missed" in the transition from the ER to the floor, even if the labs were drawn in the ER, if the patient were transferred with things pending.

I think this is a process problem for the hospitalist service, and should not be solved at the expense of the ER.

I proposed a solution. A general policy that the ER would provide "complete" workups while the admitting docs (not just the hospitalists) would be willing to accept some admits, on an exceptional basis, without the complete workup.

Further, what constitutes a "complete" workup would be negotiated. I prefer the term "adequate" workup.

For example. 54 year old man with HTN and DM, presents with new onset of exertional chest pain, relieved in the ambulance with two sublingual nitros. Nonspecific EKG changes, neg cardiac enzymes (15 minute turn-around POS testing) and neg CXR. Fingerstick glucose.

This would be about a 15-30 minute ER workup. Complete with ASA, Lovenox, initiation of beta-blocker, etc.

I don't think anything else would be necessary for the admission consideration. The admitting physician might want a CBC, metabolic panel, lipids, etc., but these don't need to come from the ER.
Now this is a medical development I can get between:
Musical breast implants

Computer chips that store music could soon be built into a woman's breast implants.

One boob could hold an MP3 player and the other the person's whole music collection.

BT futurology, who have developed the idea, say it could be available within 15 years.

BT Laboratories' analyst Ian Pearson said flexible plastic electronics would sit inside the breast. A signal would be relayed to headphones, while the device would be controlled by Bluetooth using a panel on the wrist.

According to The Sun he said: "It is now very hard for me to thing of breast implants as just decorative. If a woman has something implanted permanently, it might as well do something useful."

The sensors around the body linked through the electrical impulses in the chips may also be able to warn wearers about heart murmurs, blood pressure increases, diabetes and breast cancer.

Sunday, November 06, 2005

Blogging this from my new Treo 650. Hope I don't get Blackberry thumb!

Tuesday, November 01, 2005

As I started to read about Judge Alito, I began to think that I would be supporting him. Then I read this.

Now, normally, I am not persuaded by emotional arguments. But this one is so heartfelt, so full of life and energy, that I couldn't help but be persuaded. Just read the eloquent prose, the masterful use of imagery. I have never seen so many hyphens in one essay!

Who could resist the image of Drudge as an "loathsome little egg-humping f**ker?" Not me, by golly.

Don't worry about being a lapsed Roman Catholic. As an active Roman Catholic, I will pray for you today, on this Holy Day of Obligation.

Peace Be With You.

(thanks to The Wandering Mind.