DrTony

2006-09-15T13:14:00.000-04:00

You'd think that the Jersey Democrats might try nominating people who aren't crooks.

Yeah, but how do they do that in New Jersey?

2006-09-01T11:01:00.000-04:00

I have enjoyed listening to the TCS Daily Podcasts. I heard something interesting in this podcast, featuring Stephen D. Cooper, an Associate Professor of Communications at Marshall University, about which I haven't seen anyone else comment. It is about his new book, "Watching the Watchdog: Bloggers As the Fifth Estate" and he discusses the roll of the blogosphere in policing the MSM.

The host, Ed Driscoll, asked him to "talk a little bit more about how your book defines the relationship between bloggers and the press." (at 1:40)

Professor Cooper replied, "Well, I would say the relationship is very much similar to the long-standing roll the press and the other branches of government..."

I have heard others, notably in the Pajamas Media podcasts, especially Glenn Reynolds, make the case that the press fancies themselves to be a fourth branch of government, but is was interesting to hear this Associate Professor of Communications refer to "the press and the other branches of government."

2006-08-31T16:40:00.000-04:00

Why, when we have a very robust economy, does everybody seem to think it's in the crapper? Instapundit linked to this post by John Wixted.

What is unrecognized is that today's poor aren't yesterday's poor, nor will they be tomorrow's poor. If you read Thomas Sowell, you will see that entry level wages may be flat, but people don't stay in entry level jobs. As Glenn commented about everyone he knows who owns a business, people move to new jobs for better wages. The MSM likes to report that income for "the poorest 10%" has not increased, but a sample of today's poorest 10% will show income growth over the next year. The problem with the MSM logic is that they aren't sampling the same people.

You could argue that the youngest 10% of babies are eating the same foods they were 10 years ago. This means that babies eat baby food. So what? It certainly doesn't mean that people who were eating baby food 10 years ago are still eating baby food.

So what if today's teenagers are earning the same as teenagers 5 or 10 years ago? Is it a "living wage"? It is for a teenager with no rent, utilities etc. If you are 30 years old with a family and you are working at minimum wage, whose fault is that?

Update: grammar correction

2006-08-31T09:58:00.000-04:00

Mouse Story ...

A mouse looked through the crack in the wall to see the farmer and his wife open a package.

"What food might this contain?" The mouse wondered - he was devastated to discover it was a mousetrap.

Retreating to the farmyard, the mouse proclaimed the warning.

"There is a mousetrap in the house! There is a mousetrap in the house!"

The chicken clucked and scratched, raised her head and said, "Mr. Mouse, I can tell this is a grave concern to you but it is of no consequence to me. I cannot be bothered by it."

The mouse turned to the pig and told him, "There is a mousetrap in the house! There is a mousetrap in the house!"

The pig sympathized, but said, "I am so very sorry, Mr. Mouse, but there is nothing I can do about it but pray. Be assured you are in my prayers."

The mouse turned to the cow and said, "There is a mousetrap in the house! There is a mousetrap in the house!"

The cow said, "Wow, Mr. Mouse. I'm sorry for you, but it's no skin off my nose."

So, the mouse returned to the house, head down and dejected, to face the farmer's mousetrap-- alone.

That very night a sound was heard throughout the house -- like the sound of a mousetrap catching its prey.

The farmer's wife rushed to see what was caught. In the darkness, she did not see it was a venomous snake whose tail the trap had caught.

The snake bit the farmer's wife.

The farmer rushed her to the hospital and she returned home with a fever.

Everyone knows you treat a fever with fresh chicken soup, so the farmer took his hatchet to the farmyard for the soup's main ingredient. But his wife's sickness continued, so friends and neighbors came to sit with her around the clock.

To feed them, the farmer butchered the pig. The farmer's wife did not get well; she died.

So many people came for her funeral, the farmer had the cow slaughtered to provide enough meat for all of them.

The mouse looked upon it all from his crack in the wall with great sadness.

So, the next time you hear someone is facing a problem and think it doesn't concern you, remember -- when one of us is threatened, we are all at risk.

We are all involved in this journey called life.

We must keep an eye out for one another and make an extra effort to encourage one another.

2006-08-26T10:16:00.000-04:00

You Are Superman

Faster than a speeding bullet, more powerful than a locomotive, and able to leap tall buildings in a single bound.
And pretty cute too. No wonder you're the most popular superhero ever!

What Superhero Are You?

That was interesting, I wouldn't have guessed that one.

2006-08-21T11:52:00.000-04:00

There is a bill pending in the Senate, S 2590, which would create internet access to allow us to see where our money is being spent. This bill has been held up due to a "secret hold" by one or more Senators. The telephone for the Capitol switchboard is 202-224-3121. Call this and ask your senators if they have placed a hold on this bill. I spoke with the offices of Senator Frist and Senator Alexander. Brandon, with Sen Frist, indicated he was a co-sponsor of the bill and would not want a hold placed on it. Kara, in Sen Alexander's office, had no knowledge of Sen Alexander's position but "would have someone get back" to me. You can see the list of "suspects" and cleared Senators here.

2006-07-20T15:38:00.000-04:00

Reuters does its typical job of writing an editorial and trying to pretend it's an actual news report: Bush to cast his first veto on stem-cell bill. Here, they write:

President George W. Bush will cast the first veto of his presidency on Wednesday to stop legislation championed by top scientists and desired by most Americans to expand embryonic stem cell research, the White House said.

Nowhere in the article do they support the statement that "top scientists" support the legislation. They don't quote a single scientist, by name or otherwise, or even refer to a single scientist as supportive, never mind how they might have decided who the "top scientists" were.

Additionally, the article makes to reference to any polls that indicate that "most Americans" support this legislation. I would doubt that "most Americans" even know what this legislation is about.

For example, how many of my readers know that federal funding for embryonic stem cell research was non-existent prior to the 2001 legislation signed by President Bush? Did you know that the law does not limit, nor did President Bush support limiting stem cell research, only embryonic stem cell research?

This article by Reuters repeats a common element; that is to use the broader term "stem cell research" when they are specifically addressing objections to "embryonic stem cell research." I wonder if it is deliberate.

2006-07-18T12:08:00.000-04:00

Is the customer always right? I don't think so, and neither does The Chief Happiness Officer.

I worked in a hospital where the corporate policy was to do Medical Screening Evaluations (MSE's) and to require pre-registration and pre-payment for those who we determined did not have an Emergency Medical Condition. When I started there, the ER director, a nurse administrator, explained that the corporations intent was to "train the community" in the proper utilization of the ER and to discourage inappropriate use.

A number of hospitals don't do this, both because of a fear of liability and a fear of alienating "customers." I always thought you wanted to alienate over-utilizers and those for whom you wouldn't receive payment because the insurance company would deny payment for a non-emergent condition. Additionally, if you do a good job in your MSE, there should be minimal liability.

Anyway, I told the nurse director that I would do this if it was policy but he should understand that there would be a significant number of complaints. He stated that the administration understood this.

Well, what do you guess happened? I did the screens and got complaints. Some people were grateful when the registration person told them they would have to pay if their insurance company denied the charges, but the majority were unhappy about being told their conditions weren't emergencies. After all, isn't the customer always right? I can remember being taught that a condition was an emergency if the patient determined it was.

But, geez, what about the person who shows up at 7pm on a Tuesday night requesting a refill on her Prozac? She had taken her last pill that morning and there was no reason she couldn't call her PMD in the AM for a refill, except that she owed him so much money that he refused to provide care until she started paying. Should we be required to see her and give her a prescription, with no expectation of payment?

One of my colleagues tells this story: He asked a patient one night why he had not seen his PMD for his presenting complaint, a chronic problem, and the patient replied, "I don't have any money to pay a doctor." My colleague, exasperated, replied, "I don't work for free, you know."

Anyway, the end result of my efforts to pursue MSE's was that the administration of the hospital almost fired me over the number of complaints I was getting. Now I don't disagree that a hospital should want to keep down the number of unhappy customers, but why tell me to do MSE's, knowing you will get complaints, and then criticize me for the complaints when I did appropriate MSE's. I would always have a nurse in the room when I explained it to the patient and the consensus was that I did a good job and was not rude or insensitive in my presentation to the patient.

2006-05-07T04:20:00.000-04:00

Researchers Chart Leap in Mac Vulnerabilities

The volume of security vulnerabilities discovered in Apple's Macintosh platform has increased significantly over the last several years, according to a new report released by McAfee's Avert Labs.

The security software maker contends that the number of flaws found in the Mac operating system has increased by 228 percent since 2003. While the researchers said the number of serious vulnerabilities isolated in the latest version of Apple's operating system software, Mac OS X, is dwarfed by the quantity of problems unearthed in Microsoft's rival Windows during the same period, McAfee maintains that as Apple's products have become more popular, a larger number of glitches are being identified.

Gee, I hope there's no conflict of interest in this report.

Oh, wait, there's more:

For its part, McAfee released the findings alongside the announcement of its new package of anti-virus applications for Apple's Intel-based Macs. The vendor's VirusScan for Mactel 8.0 release runs under Apple's Rosetta emulator and promises protection from both Macintosh- and Windows-oriented viruses, as well as Trojans and other threats.

2006-05-04T12:36:00.000-04:00

Just wondering, is there a basis for a lawsuit against the New York Times based on the newsrag's publication of classified data? Don't we, as citizens, have the right to see that our tax dollars are spent wisely? Isn't the money wasted trying to defend legal policies or trying to investigate leaks of classified information? If the NYT violated the Espionage Act by publishing classified data, didn't it waste our tax dollars?

What about the lies in the Washington Post about secret prisons in Europe? With no evidence that this was true, this newsrag published what it believed was classified information, costing the US taxpayers huge amounts of money.

And the damage to our countries reputation? Is this libel? Other countries will be more reluctant to deal with the US if their own secrets won't be protected.

What about our security? The individual security of each citizen. Let's say that a group of terrorists is plotting to blow up Oak Ridge. They avoid using cell phones because the NYT has illegally published classified data. They aren't caught and successfully blow up Oak Ridge. My wife is in Oak Ridge for a dog show and gets killed. Has the NYT committed second degree murder? Wasn't this willful disregard for the consequence of their actions? Do I have a civil suit for wrongful death?

2006-05-04T12:33:00.000-04:00

In the WSJ, an article describing the success related to med-mal reform:

The Senate is once again taking up the issue of medical justice reform. If senators want to expand access to health care by increasing the number of physicians and lowering costs, they need to look at Texas.

In the summer of 2003 the Texas Legislature enacted important medical litigation reform. A voter-approved constitutional amendment, Proposition 12, followed later that year to solidify the changes. As a result, physicians are returning to the state, particularly in underserved specialties and counties. Insurance premiums to protect against frivolous lawsuits have declined dramatically, with the state's largest carrier reporting declines up to 22% and other carriers reducing premiums by an average of 13%. The number of lawsuits filed against doctors has been cut almost in half.

Prior to the successful reform effort, personal injury lawyers had put Texas doctors on the run. According to the Texas Department of Insurance, the frequency of claims was increasing at a rate of 4.6% annually--between 1996 and 2000 alone, one out of four doctors was sued.

2006-05-03T08:13:00.000-04:00

A Day Without Immigrants (DWI))

What a concept. So were we to imagine that every person with whom we interact on a daily basis, who wasn't born in the US, will simply be unavailable on May 1?

My father-in-law was born in Mexico. He immigrated, legally, to the US about 50 years ago. He married a woman who was born in the US, but both of whose parents were legal immigrants from Mexico. So, everybody who lives in my house, except for me, is Mexican.

F-in-Law hates the concept of amnesty for illegal immigrants. His attitude is that he did it right, waited, got in and succeeded. Why should someone be allowed to break the law, for whatever "admirable" motive, and then just say, "Oops! My Bad!" and just be forgiven?

On May 1, I was working in the ER. One of my patients was a young man who had a work-place injury to his foot. He commented, "You know, Doc, I shouldn't have been at work today, anyway." He referred to the DWI. He is a natural born citizen of the US; his parents were both immigrants from Mexico. I asked him what he thought about amnesty for illegals. He replied that it bothered him that so many people wanted to make criminals out of the immigrants. I thought I was in for the usual liberal arguments, but before I could reply that they made criminals out of themselves when they broke the law, he laughed and said, "Well, I guess they did that themselves, didn't they?"

He then replied that he was conflicted. You see, both of his immigrant parents were illegal, but were now citizens after the amnesty under President Reagan. He didn't want to criticize current illegals because that would mean criticizing his parents.

However, he moved from El Paso because he couldn't compete with the overwhelming number of illegals for jobs. The argument that illegals are simply doing the jobs that "Americans" don't want to do is bunk. He works for a construction company, legally, pays his taxes and expects a certain income. The problem is that, because he works in a labor job, he doesn't have much job security. Every day there is a line of illegals waiting for his foreman, trying to take his and other jobs. They don't just work for less per hour, but there is none of the beuracratic overhead associated with legal employees.

As with every other employee that works "off the books" the employer doesn't have to pay worker's comp, taxes, etc. Now, I know that some do, and even help the illegal get forged documents. OTOH, if this guy had been an illegal working for end of the day cash, he would have been on the hook for a several hundred dollar ER bill. The employer could have just told the guy, "Hey, if you're hurt and can't work, just get out of here!" and taken the next guy in line.

So, my patient works for less per hour, to protect his employment, than he would have to earn if he wasn't competing against illegals. He is concerned that he can't provide for his kids adequately because of this. He feels that the increased income he could have if he wasn't competing with illegals would allow his wife to be a stay at home mom.

Mixed feelings.

BTW, I am a first generation US citizen. My mother immigrated legally and became a US citizen in the 1960's.

2006-05-01T09:57:00.000-04:00

I appreciate the people who have been checking back and wondering where I am. I have been working a great deal, actually more than 2 full time jobs. I will be sliding back into doing some blogging, but my free time has gone to my family.

BTW, check this out. I just got it for my birthday and it works great. I had a bluetooth headset for my older Ipod, but it wouldn't work with my video Ipod. This one works fine and even works flawlessly with my Treo.

2006-02-10T07:54:00.000-05:00

State lawmakers say imminent domain is hot topic

Leaders of both parties said their constituents are upset about a U.S. Supreme Court decision last June that allows governments to forcibly buy property from its owner for development by another private owner.

"There have been 17 bills on this filed in the Senate and it's just Thursday," Senate Minority Leader Jim Kyle, D-Memphis, said during The Associated Press-Tennessee Press Association legislative planning session Thursday.

Senate Majority Leader Ron Ramsey, R-Blountville, said he expected legislation to pass outlawing governmental taking of property for private development.

"Eminent domain is something that's on everybody's mind," Ramsey said. "It's mostly what I hear about back in my district."

So at least someone's trying to get it right.

2006-02-10T07:42:00.000-05:00

Knoxville woman charged with TennCare fraud

An indictment accuses Hill of knowingly trying to use her TennCare benefits to pay for a fraudulent prescription for the painkiller Lortab, a brand version of hydrocodone.

Obviously, we all understand the problem of prescription fraud. My first thought about this article was a little different.

Does this woman ever think about the fact that she is stealing from poor people? By taking this money out of the TennCare budget, she is taking money that could be used to provide care for the indigent.

This isn't a matter of stealing from the tax collector. This money was destined for the indigent, having already been taken from the rich by the government.

What would she say if someone suggested to her that she steal $15 buck from a mission house to buy Lortab? Wait, don't answer that.

2006-02-10T07:32:00.000-05:00

Chrysler's LaSorda calls for lawsuit reform
Just a reminder that the tort/malpractice problem in our country is more than just medical. How much of the cost of any product is due to the lawyers?

2006-01-30T16:15:00.000-05:00

On my wish list: Myvu

2006-01-30T15:36:00.000-05:00

Obesity Contagious?

There is accumulating evidence that certain viruses may cause obesity, in essence making obesity contagious, according to Leah D. Whigham, the lead researcher in a new study, "Adipogenic potential of multiple human adenoviruses in vivo and in vitro in animals," in the January issue of the American Journal of Physiology-Regulatory, Integrative and Comparative Physiology published by the American Physiological Society.

OK, I can accept that a virus may make you hungry, but taking in more calories than you burn is what makes one obese. The article describes "adipogenic potential." Does this mean that the virus might make adipose out of nowhere? Or does it mean that there is a greater potential for imbibed calories to be deposited as adipose as opposed to used for some other reason?

No matter what infection you get, if you eat 1500 calories a day and burn 2000, you will not get fat.

2006-01-30T12:20:00.000-05:00

Well, this certainly explains a lot about my social life in high school:

He believes the genes which make someone analytical may also impair their social and communication skills. A weakness in these areas is the key characteristic of autism."

2006-01-29T15:25:00.000-05:00

Hey, TWM! Is this you?

2006-01-28T22:05:00.000-05:00

Single workout can lift mood in depressed patients

A single 30-minute walk on a treadmill can give a temporary emotional lift to patients diagnosed with major depressive disorder, the results of a small study suggest.

Researchers found that among 40 men and women recently diagnosed with major depression, those who spent just a half hour on a treadmill reported a short-term improvement in energy and emotional well-being.

Though a single workout is not the answer to clinical depression, the researchers say, exercise could offer depressed patients a way to give themselves an emotional boost.

Works for me.

2006-01-28T21:57:00.000-05:00

Now, this is cool. Helpful and informative, too.

2006-01-28T20:11:00.000-05:00

This may be the only thing that could get me to vote for Diane Feinstein.

2006-01-28T19:34:00.000-05:00

Hospitals may want to rethink cell phone bans

The prohibition against mobile phones in hospitals may do more harm than good, a new report reveals.

Medical facilities prohibit cell phone use, but some doctors already use them. And it turns out they reduce medical errors because communication is more timely, a new study finds.

Mobile phones rarely cause electronic magnetic interference, Yale School of Medicine researchers reported today.

2006-01-28T18:23:00.000-05:00

FDA Approves Inhalable Insulin

The first inhalable version of insulin won federal approval Friday, giving millions of adult diabetics an alternative to some of the injections they now endure.

The Food and Drug Administration said the Pfizer Inc. insulin, to be marketed as "Exubera," is the first new way of delivering insulin since the discovery of the hormone in the 1920s.

Pfizer jointly developed the drug and dispenser with Sanofi-Aventis and Nektar Therapeutics. It should be available to patients by midyear, Pfizer said.

Cool beans.

2006-01-27T10:31:00.000-05:00

Prize for DNA Decoding Aims to Fuel Innovation

When inventor Burt Rutan's SpaceShipOne soared 63.6 miles above the Earth in October 2004, he captured the $10 million X Prize and helped inaugurate the era of commercial human space flight.

The X Prize Foundation, a nonprofit-education organization, is looking to spur a new adventure -- into human genes.

The Santa Monica, Calif., foundation plans to offer a $5 million to $20 million prize to the first team that completely decodes the DNA of 100 or more people in a matter of weeks, according to foundation officials and others involved.

Such speedy gene sequencing would represent a technology breakthrough for medical research. It could launch an era of "personal" genomics in which ordinary people can learn their complete DNA code for less than the cost of a wide-screen television.

Details of the award are being worked out, and officials say they don't expect anyone to claim the prize for at least five to 10 years.

Hey, let's get started!

2006-01-27T09:34:00.000-05:00

So who gets to define normal, anyway?

Experts Say Biology Makes It Harder for Boys to Behave

The problem is, define behave. So boys act like boys. What's the big deal? Our society has defined that boisterous behavior is "not behaving." Isn't this just as wrong as saying that being willing to sit still for hour after hour is abnormal?

Why should we define "behaving" or "normal" in such a way as to exclude 50% of our kids from that category? What about a girl who likes to be active?

Well, if it's tough to control the classroom, sedate those suckers!! Give 'em drugs because we don't want to have to find a way to educate them that accomodates/utilizes their behavior.

Doug Anglin complains that his high school makes it easier for girls than for boys to succeed academically, and the Massachusetts teenager is now trying to prove it to the federal government.

It may sound like sour grapes, but some experts believe Anglin has a point.

In the complaint that he lodged with the U.S. Department of Education's Office for Civil Rights, Anglin, 17, claimed that girls faced fewer restrictions from teachers at Milton High School in Milton, Mass., and that boys were more likely to be punished.

"The system is designed to the disadvantage of males," Anglin told The Boston Globe. "From the elementary level, they establish a philosophy that if you sit down, follow orders and listen to what they say, you'll do well and get good grades. Men naturally rebel against this."

The complaint comes at a time when boys' struggles in school are getting close examination. According to a 2005 report by the Educational Equity Center of the Academy for Educational Development in Washington D.C., boys around the country are increasingly falling behind girls academically, and are more likely to get suspended. And experts told ABC News that Anglin's assessment has merit and describes what prevails in most American classrooms.

"I think he's got it basically right, although I don't believe the system was set up purposely to hurt boys," said William Pollack, director of the Centers for Men and Young Men at McLean Hospital of Harvard Medical School.

Pollack and others noted that in general young boys in kindergarten and first grade are not able to behave as well as girls due to biological and social differences. He said that up until fifth grade, boys require five to seven recesses a day, though most get just one. "With a boy who squirms, you take away his recess," he said, "so then he either acts out and we say he's a discipline problem, or he's very active and we say he has hyperactivity."

...

"We have the data about learning-style differences and behavior-style differences," he said. "This is not a win-lose circumstance. It's not teachers against parents, parents against schools, boys against girls. It's a win-win. We recognize what we now know and use it."

Pollack also said:

The increased focus on testing in schools has also ratcheted up pressure on young students, he said. "In kindergarten, I had to learn … to socialize," he said. "Today they read and write. Some boys can. Most can't. There's a biological component."

Wow, what a thing to say! Can you imagine the reaction if someone stated that girls can't do something because of a "biological component?" We can't even argue that girls don't make good football players in high school without someone bringing up that girl that went to my second cousin's friends school in Mississippi who was the best football player at her school.

UPDATE: I would like to point out that DrHelen wrote about this as well. Her comments here.

Last night I listened to the podcast from Glenn and Helen with Norah Vincent. Get it here. Norah talked about how men don't have it as easy as many women, and some men, think they do. Specifically, she commented that many men don't know what they are missing. Men don't understand or appreciate the "freedoms" they are missing out on, because they have never had them. As a woman masquerading as a man, Norah felt limited in ways that she had not been as a woman, and missed them.

Boys growing up nowadays don't know that they are normal, just different from girls. Our educators should stop trying to force round pegs into square holes and using Ritalin as grease.

2006-01-27T08:21:00.000-05:00

Geez, I mean, come on. When do you stop this crap? How many people are going to die so a few environmental wackos can feel better about the ozone layer?

FDA May Make Breathing Difficult for Asthmatics

The government may tell asthmatics to "take a hit" for the environment. But that "hit" won't be from their inhalers, which might be taken away.

A Food and Drug Administration advisory panel voted this week to recommend removing the "essential use" status that permits inexpensive, nonprescription asthma inhalers, like Primatene Mist, to remain on sale.

Powered by chlorofluorcarbon (CFC) propellants, the inhalers shoot epinephrine into the lungs of asthmatics, allowing them to breathe during potentially life-threatening asthma attacks. But environmentalists labeled CFCs a threat to the ozone layer in the 1980s, leading to an international phase-out of CFCs under the 1987 Montreal Protocol.

...

First, accepting for argument's sake that ozone depletion alarmism is justified, only a trivial amount of CFCs would be released into the atmosphere due to inhaler use. No detectable damage to the ozone layer would likely result.

...

No one disputes the basic chemistry of ozone depletion – chlorine atoms from CFCs released into the environment can find their way into the stratosphere where they can chemically react with and "destroy" ozone.

It should be noted, however, that CFCs aren't the only source of chlorine atoms in the stratosphere – Mother Nature, in fact, may supply most of them. Also, ozone is also continually being created so we won't ever run out of ozone.

In any event, none of the alleged environmental and public health horrors of CFC-induced ozone "destruction" have ever been observed despite extensive study – one of the best kept secrets of environmentalism.

While overexposure to UV is a risk factor for some types of skin cancer and cataracts, no scientific study has ever demonstrated a link between ozone depletion and such overexposure or any health effects.

How many people are suffering every day to save a very few the potential ill effect of Vioxx? Better question, how many have died from GI bleeds resulting from non-selective NSAIDs that they were forced to use when Vioxx was withdrawn?

We need to think about the effect of what we do, not just what makes a few feel better.

Quick review: No scientific evidence to link ozone depletion with disease. No evidence that the very small amount of CFC's in inhalers affects the ozone in any significant way. No research into how many lives are saved every year by inhalers utilizing CFC's.

Go figure.

But a few people will feel better because their pet cause is getting a lot attention. They won't even know about the asthma exacerbations and deaths I will see in the ER because people can't get their meds.

2006-01-26T22:39:00.000-05:00

Like a RSS site feed for good medblog stuff: Sneezing PO

2006-01-26T20:37:00.000-05:00

Yeah, but the hiccups are gone, aren't they?

2006-01-26T20:24:00.000-05:00

You should go here and read this blog. I found it because she is the host for next week's Grand Rounds. I love the name. Barbados Butterfly

2006-01-26T19:07:00.000-05:00

So here's an interesting, at least to me, issue. Many of my colleagues, and most of the nurses, will check a blood alcohol on patients who have been drinking. Why?

If they have an altered mental status, the BA may help explain it, but you are going to have to work the patient up anyway. Why not do your work-up without checking the BA? What does the BA add? I would be concerned that an elevated BA might make you less aggressive about your work-up and you could miss something.

The other problem is the disposition problem. If you discharge a patient with documentation of safe gait, an understanding of his situation and an understanding of his discharge instructions, but without a BA, that should be sufficient. If he gets in a problem later, you don't have a pesky BA to explain.

If you discharge that exact same patient with a BA of 150 and then anything bad happens, you have to explain the BA. So the tendency in the ER is to keep the patient until the BA is less than 100. Why 100? Well, that has traditionally been the "legal BA." I often here referrence to "legally drunk."

Help me, Curious JD, but what exactly does legally drunk mean? It isn't against the law to be drunk, is it?

Of course, it is against the law to drive drunk. But we aren't releasing these patients to go drive. Just to walk to a car, driven by someone else, go home and go to bed.

Besides, the legal definition of DUI changes, doesn't it? Here in TN, it is now 80. But those same people feel OK about discharging a BA of 90.

Besides, we've probably all seen someone with a BA of 150 that could pass a field sobriety test, haven't we?

So my theory is this: Don't check the BA. If you think the patient is not safe to discharge, don't. If you think he is safe, document your findings that support your opinion and discharge.

If you are keeping a patient in the ER, or admit for OBS because of an elevated BA, are you suggesting that this person represents a risk to themselves or others? If not, why are you keeping them? If so, this would mean, potentially, an involuntary commital/admission.

What if the patient wants to leave, but you have a BA of 200 on the chart? Let's say that this is a chronic drinker, a frequent-flyer who is always drunk. Someone who comes to the ER, asks for a dinner tray and then wants to leave after he eats. His speech is fluent, maybe his gait is slightly antalgic. He knows where he is, what day it is and understands your instructions.

Do you let him leave? Do you call the police/security to keep him in the hospital?

Do you have a locked ward?

If you have admitted/kept in the ER a patient with the goal of discharging when the BA is less than 100, are you substituting this lab for your clinical judgement? What happens when you go in the room and the patient has eloped?

Give me your opinions about this situation. Under which circumstance would an ER doc be at greater risk if a patient leaves the ER and causes someone else to be injured:

A patient is discharged with careful documentation of the ER doc's findings of an apparently safe condition, but without any BA

A patient has a BA of 150, but the ER doc has documented findings of an apparently safe condition

A patient has a BA of 90, but the ER doc has not documented specific findings of an apparently safe condition

A patient has a BA of 150 and the ER doc has felt it necessary to keep the patient until the BA is less than 100, but the patient left without discharge

In the last situation, is the ER doc/hospital liable for not protecting the patient/community from this "legally drunk" patient?

2006-01-26T16:46:00.000-05:00

Working in ER today. Just saw this chief complaint:

Hit elbow on peace of medal (steal)

2006-01-18T18:54:00.000-05:00

Court permits contingency fee waiver

Passed by voters in November 2004 as Amendment 3, the law limits attorneys' fees to 30 percent of the first $250,000 recovered and 10 percent of all damages in excess of that amount in medical malpractice cases.

Since its passage, some trial attorneys have had medical malpractice claimants waive their rights under the fee cap. The attorneys said such cases are too expensive to bring under the smaller fees.

Too expensive? I thought expenses came off the top.

Anyway, look at this:

"We will work to warn the public about the procedure that greedy lawyers will be using to take an unconstitutional share of the client¹s funds," the FMA said in a statement on its Web site. "And if the procedure does not include judicial oversight, the FMA believes that physicians in Florida will be able to follow the same procedure established by the court to have potential patients waive their right to bring a medical malpractice action against the physicians. The FMA will advocate the use of a similar form and waiver procedure for physicians to use in their practices."

What would motivate a patient to sign away their right to sue? And what court wouldn't ignore the waiver if signed? If you told a patient he needed a procedure and then required he sign a waiver before you would do it, his attorney would just argue that he believed the only way to get this "life-saving" procedure would be to sign the waiver.

2006-01-17T15:12:00.000-05:00

For extraordinary heroism as Combined Anti-Armor Platoon Commander, Weapons Company, 3rd Battalion, 5th Marines, 1st Marine Division, I Marine Expeditionary Force in support of Operation IRAQI FREEDOM on 25 March 2003. While leading his platoon north on Highway I toward Ad Diwaniyah, First Lieutenant Chontosh's platoon moved into a coordinated ambush of mortars, rocket propelled grenades, and automatic weapons fire.

Many say that the Army is broken. Some of our troops are on their third deployment. Recruitment is down, even as our military has lowered its standards. Murtha

With coalition tanks blocking the road ahead, he realized his platoon was caught in a kill zone. He had his driver move the vehicle through a breach along his flank, where he was immediately taken under fire from an entrenched machine gun.

Iraq can not be won “militarily.” Murtha

Without hesitation, First Lieutenant Chontosh ordered the driver to advance directly at the enemy position enabling his .50 caliber machine gunner to silence the enemy. He then directed his driver into the enemy trench, where he exited his vehicle and began to clear the trench with an M16A2 service rifle and 9 millimeter pistol.

the U.S. can not accomplish anything further in Iraq militarily.
Murtha

His ammunition depleted, First Lieutenant Chontosh, with complete disregard for his safety, twice picked up discarded enemy rifles and continued his ferocious attack. When a Marine following him found an enemy rocket propelled grenade launcher, First Lieutenant Chontosh used it to destroy yet another group of enemy soldiers.

…the United States now has a mercenary army. Professor David Kennedy

When his audacious attack ended, he had cleared over 200 meters of the enemy trench, killing more than 20 enemy soldiers and wounding several others.

And there is no reason, Bob, that young American soldiers need to be going into the homes of Iraqis in the dead of night, terrorizing kids and children, you know,… Senator John Kerry

"And I think you're saying the average guy out there who's considering recruitment is justified in saying 'I don't want to serve,"' the interviewer said. "Exactly right," Murtha replied

By his outstanding display of decisive leadership, unlimited courage in the face of heavy enemy fire, and utmost devotion to duty, First Lieutenant Chontosh reflected great credit upon himself and upheld the highest traditions of the Marine Corps and the United States Naval Service.

Who's the patriot? Citation here.

2006-01-14T14:13:00.000-05:00

With a cool new header, the blogger formerly known as the Medical Madhouse now is Doctor. Go check him out!

2006-01-13T10:57:00.000-05:00

Unbelievably horrible.

Young men with bats kill homeless man, injure 2 others in downtown, beachside Lauderdale

2006-01-11T13:13:00.000-05:00

Thinking about buying one of these. What do you think?

2006-01-11T08:41:00.000-05:00

If you want to get rid of something, sic the trial lawyers on it. Say goodbye to affirmative action.

2006-01-09T16:53:00.000-05:00

After years of ER shift work, Dr. John Moone had no problem sleeping anywhere, anytime. Having just fallen asleep after a string of night shifts, he was surprised when he woke up after only 1 hour of sleep. Then he heard it again. A noise in the living room. There was definitely someone in his apartment!

Wrapping his robe tightly around him, he crept to the door and carefully looked out. There, sitting on the couch, were two people, looking directly at him.

"John, come on out. There is no danger here," said the short, bald man.

"My associate is Peter. I am Sheila." The equally sort, somewhat pretty woman gestured to him to sit in the chair.

Tentatively, John came forward and settled lightly on the edge of the chair, like a cat ready to run at the first sign of trouble. "Who were these people and how did they get in?" he asked himself. Normally very security conscious, he had multiple locks on his door, which appeared undisturbed. No broken windows, either.

"We mean you no harm. We need your help. If you will give us a few moments, we will explain why we chose you and what we need." What was her name? Oh, right, Sheila.

"I want you two to leave. I'll call the police." His stern tone belied his fear and anxiety.

"Please, just a minute of your time." Laughing, Peter added, "Yes, Yes, just a minute."

Confused, but settling down, Peter inquired, "How did you get in?"

"All in due time," was Sheila's answer. Peter snickered, "Due time, how good. Due time."

"Peter, please. Let me explain to Dr. Moone." Turning slightly to face away from Peter, Sheila directed her comments to John. "We are going to tell you some things that will seem very fantastic. You may have trouble believing us. However, you were chosen as someone who would be more likely to accept the ideas we will share."

"Chosen? What do you mean chosen?"

"We have access to full information regarding everyone who has ever lived, anywhere on Earth. This information was screened and our, um, computer might be the best word, indicated that you had the best combination of qualities," answered Sheila, calmly.

"What information? What qualities?" The rising pitch of his voice betrayed his level of anxiety.

"Let me show you something and then answer your first question. Then you might be ready for more information. Come here with me." Sheila indicated the window across the room.

John walked with her to the window. Surprised that he could attend to such things, John noticed the pleasant smell of her perfume.

As he looked out the window, John suddenly felt lightheaded and reached for the window frame to steady himself. There was nothing recognizable out there! Where was the courtyard, the barbeque area or the lap pool that had convinced him to live here? All he could see was more apartments. He seemed much higher than his second story apartment should have been. He looked out on what must have been hundreds of apartment buildings. All the same, it had the appearance of the "projects" in which he had been raised. "What's going on here?" he cried, slipping to the floor.

"Some things have changed. Someone important has died who shouldn't have. Many years ago, actually," Peter added to the conversation.

"And this happened? How could today be so different from yesterday because someone died some time in the past?"

"You asked how we go into your apartment. Nobody has locks on their doors. It might interfere with 'official entry requirements' according to the current regime." Sheila rolled her eyes.

"Careful!" came Peter's voice from across the room. "We can't be 100% sure that the monitors are off."

"Sorry. You're right. I better get to the point. John, one of the reasons you bubbled to the top of the list is because of some books you bought on Amazon. You demonstrated an interest in 'alternative history' type stories." Sheila's voice was gentle, trying to lead him along.

"You mean those books by Turtledove? And how do you know what books I bought?"

"We told you," Peter sounded irritated, "We know everything about you."

"Yes, those books," replied Sheila, with a disapproving glance towards Peter. "You seemed likely to accept the concepts we are going to share with you."

"Oh, jeez. Just tell me what is going on."

"We are from the future. Or, rather, a future." Sheila's head rocked with the force of John's interruption.

"Oh, come on!" He screamed. "You guys are nuts. What drugs did you give me? What the hell is going on here? Who are you?"

"John, please..." Sheila began.

"I told you this wouldn't work," Peter interrupted. "We should have drugged him and taken him, like I said."

"Peter, let me explain. I think he will understand," Sheila answered.

"Somebody explain, or get the hell out!" shouted John.

"John, sit down. Promise me you will listen for 5 minutes without interruption. I'm sure you will understand." Sheila's soft tones had the desired effect, calming John.

"As I said, we are from the future. Actually, just like in the books you have read, the future is malleable. Something happened to alter the timeline with which you are familiar. Someone broke the rules and altered the past. We are here to ask you help fixing that."

"Help fix what? Why me?" questioned John.

"As I said, I will explain. Just follow along. You were chosen for several reasons. You have read a great deal of science fiction, fantasy, especially alternate history type books. Well, this is like one of those stories. We thought you might be more accepting, given your interest.

"Additionally, you are an experienced medical doctor. You have skills we need. You see, as the world became more peaceful, less time and energy was spent on war and crime, so our healers don't have any skills in trauma care. Advances in infectious disease management has wiped out what you would consider infections and resulted in additional lost skills. Imagine someone in your time asking you to perform a procedure that hasn't been taught for centuries. You wouldn't be able to do it.

"We are here to ask you to travel with us and help repair time, so to speak. The world you see outside your window is the result of a change in an event hundreds of years ago that has been amplified through the years.

"As you know, in the latter part of the 18th century, your country fought for independence from Great Britain. The leader of that fight was George Washington, who went on to become your first president. What do you think would have happened if he hadn't been in that role? Some things may have been drastically different, and some may have been very similar. Look at your money."

John walked to his hall table and picked up his wallet. In it he found a red and white piece of paper with a very unfamiliar picture on it.

"What is this? Who is this? What happened to my money?"

"Someone has changed what you thought was history. George Washington died during the winter at Valley Forge. He never became your president. As a matter of fact, the colonies lost the war and remained under the rule of Great Britain."

"But if, as you suggest, those things changed, how can I remember the previous history?"

"I better let Peter address that," answered Sheila.

"John, that is a great question, and very perceptive. We don't understand everything that happens with time shifts," explained Peter. "That's one of the reasons we have tried so hard to prevent these things from happening.

"The best we can come up with is that some people are unaffected. For some reason, people like you awaken in what seems like a new world, but with memories of the previous history. Some people are able to adjust and fit in, others have been locked up in mental hospitals. As we have recognized what we call 'alternative history syndrome,' we have created 'neighborhoods' for these people. Sometimes hundreds of people remember the same history.

"Interestingly, at times, some people will simply live on in their new life as if nothing had changed. They appear to live in total denial of what they had done or said previously and proceed as if their new life was what had always existed. For example, in your day, there was blogger who supported your President Bush and the Iraq war. Suddenly, his writing shifted 180 degrees, without any explanation, and he was adamantly against those same issues.

"OK, OK, so what do you want?" asked John.

"We need you to go with us to Valley Forge, January 1778. We don't know why General Washington died or how to fix it," Sheila replied.

"Why change it?" John queried. "What's wrong with the alternate history? Do you try to go back and fix other shifts?"

"Peter..." said Sheila.

"Right. Another good question. This change was not accidental, nor was it the result of a natural temporal shift. Sheila and I work for a company that runs, well, what you would call a time tourism business. Someone broke the rules and caused this shift." He glanced nervously at Sheila. "Instead of, at most, a few hundred people not following the shift, this has pretty much split down the middle. Half the world is living in one history, half in the other. You can imagine the problems that are resulting. The results are mixed. Someone like you remembers one history but is living in a community caused by another history. That is why the view out your window is so odd."

"But what can I do?" asked John.

"We need your medical skills. We need you to travel to Valley Forge and examine General Washington, diagnose him and treat him."

"But how do I travel? What if I can't figure out what is going on? What equipment/supplies can I take with me?" So many questions filled his brain that only a few could slip out.

Peter answered, "We cannot venture outside this apartment. You can bring anything you have here that you think will help. We may be able to get a few things, but the world out there is very different from what you remember, and, frankly, very dangerous."

Jane added, "Get what you can and come back here. Time is short."

"Ha, ha." Peter snorted, "Time is short."

Dr. Moone grabbed his lab coat that contained his stethescope and penlight. He had a suture kit in the other room, along with the Augmentin he had picked up to take to his mother later that day.

As he walked back into the living room, he saw Peter fiddling with a small handheld device. "Ready?" Peter asked.

"Ye...."

Looking around, John saw Peter and Sheila standing in front of him. They were wearing different clothes, things he recognized from history books. Glancing at a nearby window, he realized that he, too, was wearing period clothing. In his pockets, he felt his stethescope and the bottle of antibiotics. He saw Peter holding an attache with his suture kit in it.

The building next to him had a sign in the window that said, "Long Live the King of Prussia." He realized that he was only about 2 miles away from Valley Forge, in what he new as King of Prussia, Pennsylvania. This must be the King of Prussia Inn, where George Washington wintered Valley Forge.

He followed Sheila and Peter into the small inn. A man was waiting for them and brought them to a small first floor room where a man was lieing on the bed. The aide gestured for John to come forward.

The man on the bed was slightly diaphoretic and tachypneic. Reaching down, John could feel a strong pulse at General Washington's wrist, with a heart rate about 120. Good color and the fingernails pinked up quickly after being compressed.

"Has he been eating?" John asked the aide.

"Yes, Doctor. But poorly. He says he has no appetite and thinks he should try to eat light, anyway, to spare food for the troops."

Listening with his stethescope, he heard clear breath sounds and a regular heart beat. "Has he been injured?"

"Four days ago he stepped on a sharp bone in the field. It pierced his boot and his right foot."

Pulling the blanket aside, John recognized the smell of pus. As he examined the right foot, he saw that it was diffusely swollen and red. The foot was swollen and the patient winced when John moved it.

"Sir, can you help me? I need to get back to my men?" General Washington had awakened.

"I believe I can," John answered. He thought to himself, "Wow, this is really him. Should I ask for an autograph?"

"Will you have to amputate?" the aide asked.

"No. Sir, you have an infection of your foot. I need to examine the wound more closely to see if there is any foreign body in there. This will be unpleasant." He opened the suture set and began to probe the wound. He removed two small slivers of bone and washed the wound carefully, as he said, "Dilution is the solution to pollution.

"Here, take these pills. One pill twice a day. That is the best I can do."

After years of ER shift work, Dr. John Moone had no problem sleeping anywhere, anytime. Having slept after a string of night shifts, he awoke as the alarm sounded. He hopped quickly out of bed and ran to the window. There was his familiar view of the lap pool.

"I guess it was just a dream," he thought as he searched for the Augmentin he had picked up for his mother.

2006-01-01T20:47:00.000-05:00

In an earlier post, I mentioned the AAEM's beginning a Remarkable Testimony project. The first case listed was with regard to the testimony of Dr. Tarlow who made some real woppers. On another blog, I called his testimony "crap" and was asked what I meant by that. Here are further comments:

Page 7: "And, in fact, half the people practicing ER medicine are not board-certified." He doesn't support this statement and I certainly doubt it. Almost every doctor I've ever been associated with in an ER has been board certified. Maybe not in emergency medicine, but board certified.

Page 7: "The American Medical Association really mandates people take examinations every few years." We all know that the AMA has nothing to do with board examinations and some boards do not require recertification.

Page 12: "...people with seizures don't develop seizures at age 50, okay, unless there's a tumor or aneurysm or something bad. People who have seizures at 40 or 50 typically have had them for many, many years, generally as an adolescent." It is certainly less common for older patients to develop seizures, but not so uncommon as to say it doesn't happen.

Page 14: Fast heart rate and fast respiratory rate are very non-specific and would not be useful to rule-in or rule-out a seizure. Most of the patients I see who are post-ictal are not tachycardic or tachypneic.

Page 15: Indicated that if a patient doesn't have incontinence of urine or stool, tachycardia, tachypnea, no history of seizure disorder and negative blood tests, she didn't have a seizure. What blood tests rule out a seizure? None that I know of. It is certainly possible that a patient could have none of the above and still have a seizure.

Page 16: "Facial droop. That's a seventh nerve palsy." Facial droop can certainly be a sign of a stroke, but not if it is a seventh nerve palsy, but rather an upper motor neuron lesion. If he felt it was a seventh nerve palsy, how did he rule out Bell's Palsy?

Page 16: "...in fact, she has all these symptoms" One of the symptoms he had just referenced was "sudden loss of bowels" but had indicated earlier that she had not had bowel incontinence which would have been a sign of a seizure.

Page 17: "If a person really thinks a patient has a seizure, they really, really, really think they have a seizure, the medication is clear. It's Valium IV push, Dilantin, and phenobarbital. No question about it. That's the therapy, period. Okay?" Well, no, Dr. Tarlow, not OK. ER docs see patients every day who they feel really, really, really have had a seizure and may not use any of those drugs. Personally, if a patient is seizing in front of me, I might use Ativan, not Valium. I might not use Dilantin if it had failed for that patient in the past, or if she was allergic to it. I use phenobarbital, but rarely.

Page 18: "We'll give them Valium until they become unconscious, intubate them, and load into that--load in the Dilantin and the phenobarb, if you really think they had a seizure." WHAT THE HELL???? Dr. Tarlow, are you suggesting that every patient you see in the ER who you believe had a seizure gets intubated? And you induce with Valium alone? The incredible vast majority of seizure patients get treated without intubation.

Page 18: "The patient didn't get any of these medications, so I don't believe the doctor thought at this time it was a seizure at all." Many patients who present to the ER with c/o seizure, who aren't actively seizing, may not receive any treatment in the ER at all. Especially if it is a first seizure.

Page 18: "If a person has a stroke or a TIA, then depending on what's involved, you're going to get tPA--which is that special magic bullet drug called tissue plasminogen activator--within three hours, or heparin or coumadin..." Just not true. If a patient presents to the ER with symptoms of a TIA, either resolved or rapidly resolving, you may do nothing. Certainly, the diagnosis of TIA is an absolute contraindication to use of tPA.

Page 22: Stated that you don't give tPA in a patient with a seizure because the seizure may have been secondary to a bleed or a tumor and these would be contraindications to use of tPA. Stated "If the head is normal, despite the fact the patient really had a seizure, it doesn't matter." Yes it does, Dr. Tarlow. If you suspect the presentation is secondary to a seizure, even with a normal CAT scan, you don't use tPA. Not because of the possibility of another condition, but because you don't treat seizures with tPA. Pretty basic.

Page 22: "...even with a seizure...you'll still give them tPA." A seizure at the onset of a stroke is one of the exclusion criteria for the use of tPA in stroke. See this.

Page 23: "It's a very classic--if you've ever seen a seizure, there's no way you would not--miss that diagnosis." Other than Dr. Tarlow, I've never heard of a doctor claiming that he could never miss any diagnosis, especially one as complicated as seizure.

Page 24: Indicated that the NINDS study and the NIH have established the standard of care for stroke treatment. "That's why we have the National Institutes of Health..." This is an unfounded claim. Neither the NINDS nor the NIH establish SOC. Specifically, the American Academy of Emergency Medicine has written:
It is the position of the American Academy of Emergency Medicine that objective evidence regarding the efficacy, safety, and applicability of tPA for acute ischemic stroke is insufficient to warrant its classification as standard of care. Until additional evidence clarifies such controversies, physicians are advised to use their discretion when considering its use. Given the cited absence of definitive evidence, AAEM believes it is inappropriate to claim that either use or non-use of intravenous thrombolytic therapy constitutes a standard of care issue in the treatment of stroke.

On Page 25, he indicated that frequent checks should be recorded and that "It doesn't have to be the doctor..." Then, on page 26, he criticized the doctor because his next notation was 2 hours later.

Page 26: "...one needs to check that every 15 minutes, maybe 30 minutes..." This is an unreasonable standard, especially for a busy ER. Has anyone out there seen this as a SOC?

Page 33: In response to a question about whether the administration of tPA would have saved her life, he answered, "There's no question it would have." This is unfounded. There have been no studies demonstrating that use of tPA in stroke decreases mortality.

Page 34: "The Food and Drug Administration in very conservative. They will not approve a drug unless it is both safe and effective." Right, safe in the proper context and when the benefits outweigh the risk. However, tPA is not safe or effective in every patient. We all know that there have been drugs approved for use by the FDA that were later recalled. Vioxx, anyone?

Page 35: "...it [tPA] saves people's lives." Again, there is no evidence that tPA used to treat strokes decreases mortality from strokes.

This is commentary on Dr. Tarlow's testimony. I haven't read a transcript of the whole trial or the defendant's testimony. I can't comment on the merits of the trial or whether the defendant did or did not commit malpractice. So, Elliot, don't get on that train again. The testimony of Dr. Tarlow was full of errors and should not have gone to the jury.

2006-01-01T10:36:00.000-05:00

Is it realistic to think that the local health departments can absorb the load of the uninsured?

Gov. Phil Bredesen recently announced a Safety Net program that will give the state's health departments a total of $140 million to allow the facilities to expand medical services. Those 191,000 people cut from TennCare will have another option, with many of them being absorbed by the local state clinics.

Why does Gov Bredesen think the health departments can now handle the load when they couldn't before?

"Good management has led us to a place where we can extend medical assistance programs for the benefit of our neighbors in need," Bredesen said in a news release.

If good management can do it now, can I get a refund on all the money wasted by the previous "bad management"?

How are they going to handle this? Nurse practitioners, for one, in Montgomery County.

The extra staff coming as part of the Safety Net program includes two nurse practitioners, two registered nurses, two nursing assistants and two office assistants.

And in Anderson County:

By Jan. 3, the new primary care services will be available at 39 county health departments across the state, with eight more counties scheduled to be added later in the year, according to a press release from the Tennessee Department of Health.

Fees will be based on income, with a $5 minimum.

The new and expanded adult primary health care services are for acute and chronic illnesses, said Sandy Halford, assistant regional director at the East Tennessee Regional Health Office in Knoxville. Acute illnesses include sicknesses like sore throats, earaches and pneumonia, while chronic illnesses include high blood pressure, diabetes, arthritis and certain heart conditions.

Note this comment:

No narcotics will be offered.

New staffing in Anderson and Roane counties as well:

When fully staffed for the new services, the health departments in Anderson and Roane counties will have new staff members, including a doctor, nurse practitioner, registered nurse, certified nursing assistant and two office support workers, Halford said. New physicians have already been hired for the Anderson and Roane county health departments, she said.

It will be interesting to see how this works. I anticipate a much higher need for funding than what the Governor is now describing. These health departments are going to be overwhelmed.

I like the comment about the narcotics. These health departments are going to be inundated, at least initially, with drug seekers.

Good luck.

2005-12-31T15:24:00.000-05:00

RangelMD writes about Eight Crazy Medical Facts. Number eight:

Healthy booger eaters - And finally in the most disgusting category is the speculation that mucophagy is good for you because it boosts the immune system by exposing it to bacteria found in nasal mucus. All I know is that mucophagy is very likely to be detrimental to your social life and your odds of getting lucky. Don't do it! At least not around me.

2005-12-30T21:14:00.000-05:00

DrAndy:

Are long-acting beta agonists (LABAs) safe. I've argued in the past that they are, but now a perspective piece in the NEJM argues that they are not. (Inexplicably, it is not available as free fulltext. If you are going to publish editorials on controversial, life-threatening topics, I think you should make them available to people).

Fernando Martinez, a respected asthma researcher and participant in the FDA panel discussion about LABAs presents some new data and argues they should be used only as a last resort.

Dr. Gault wrote:

It has been the experience of pulmonary docs and allergists that for most patients the addition of a LABA to ICS is beneficial yet there may well be the possibility of a rare serious side effect.

Both doctors admit that there may be something to this issue, but, at the same time, indicate that patients and treating physicians have recognized clinical improvement in patients when ICS/LABA meds were added. Perhaps this will end up being like the Vioxx issue, where a few people are adversely affected by a drug while a great number are helped. How many people are worse off now that Vioxx has been removed from the market? How many people will see their asthma control suffer if Advair is removed from the market?

2005-12-30T09:09:00.000-05:00

The American Academy of Emergency Medicine has added section to their website called Remarkable Testimony. Here is there summary:

The number of lawsuits filed against emergency physicians is growing. The burden of dealing with these legal actions goes beyond the financial challenges of increased malpractice premiums. Other effects include time lost from work or personal time and the effects on the physician's morale. Many physicians feel that an increasing number of these lawsuits have little or no legitimate basis. These frivolous suits sometimes represent attempts to get a quick settlement from insurance companies eager to hold down costs.

In order to file a malpractice claim, many states require plaintiffs to have an opinion from an expert that malpractice has occurred. A number of these so-called experts are physicians who seem willing to make any statement, no matter how outrageous, in support of a malpractice claim. These physicians can profit handsomely from their willingness give such testimony.

Alarmingly, a number of leaders in our specialty have chosen to supplement their income by giving "expert" testimony that is unfounded in current medical standards and practice.

AAEM has responded to suggestions by several members by creating this web site. It is designed to bring to light testimony by expert witnesses that is remarkable either because of its spurious nature or because it is particularly helpful to the emergency physician defendant. It is hoped that by publicizing such testimony, and the individuals who offer it, emergency physicians may find some measure of relief from the ongoing crisis.

Here is part of the first listed:

Bertha Walker presented to the emergency department at a hospital in Kansas. She was evaluated and admitted. She was ultimately diagnosed as having a stroke and died. Later, the doctors participating in her care were sued for failing to give thrombolytic agents.

...

Dr Tarlow describes tPA as "…that special magic bullet drug…"
Comment: This highly laudatory description of tPA exceeds even the most enthusiastic endorsements of those proponents of the use of tPA in acute stroke.

Hopefully, the scorn associated with publicity may limit some of this garbage that is fed to juries. Additionally, I would like judges to understand the position of the academies, through examples like these, and rule testimony as so far outside the mainstream that allowing the jury to hear it would be prejudicial.

2005-12-29T21:16:00.000-05:00

Somebody help me figure this out. I know that CMS has all these rules about what you have to document in order to get paid, right? So, in order to bill for a day in the hospital, you have to follow the rules, right?

How does an orthopedist get paid when an entire day's progress note is "Hgb 10.2" and signature. Are they paid by the case and not the day?

2005-12-29T16:55:00.000-05:00

Don't measure glucose until you can see the whites of their eyes!

John Burd himself is quoted as saying: "People have been working on (non-invasive glucose testing) for decades and we think we've learned from their mistakes and we're coming up with a great product." Keep your eye on Oculir.

2005-12-29T16:40:00.000-05:00

An excellent discussion of the use of lethal force by law enforcement by someone who's "been there, done that."

2005-12-29T16:00:00.000-05:00

Baby Sitter Charged In Case Of Drunk 2-Year-Old

A 37-year-old man was charged with child endangerment after one of two toddlers he was baby-sitting was found drunk, authorities said.

Suffolk County sheriff's deputies investigating a family court case peered through the window of a Patchogue home Tuesday and saw Juan Reyes passed out with the children wandering around the house.

They managed to rouse Reyes, who was the only adult at home with the two toddlers, ages 2 and 3, according to the sheriff's office. The deputies said Reyes appeared extremely intoxicated.

The deputies also noticed the 2-year-old was having difficulty standing, had bloodshot eyes, smelled of alcohol and was lethargic.

The toddler was taken to the hospital, where tests revealed he was legally intoxicated, with a blood-alcohol content of 0.094 percent, the sheriff's office said. In New York, a driver is considered drunk with an alcohol content of 0.08 percent or greater.

Two things:

It's a good thing this kid couldn't find the keys to the car.

I hope the FDA approves Vivitrol for kids to prevent this kind of problem.

2005-12-29T11:24:00.000-05:00

As we move more and more drugs OTC, China goes the other way.

PEOPLE trying to buy prescription drugs in the city will actually have to show their prescription or medical report to the pharmacists starting on Sunday, as the Shanghai Food and Drug Administration tries to strengthen oversight of medication sales.

China only began dividing medications into prescribed and over-the-counter drugs in 2000. Currently, people can buy almost any prescription drug simply by leaving their names and phone numbers with the pharmacist.

The new system is being set up as a one-year pilot program.

National authorities are calling on all local governments to tighten controls on prescribed drugs, but giving them room to create their own policies.

"Prescribed medicines account for 75 percent of all drugs sold in China, but they account for more than 97 percent of reported adverse reactions," said Lan Fen from the State Food and Drug Administration. "About 41.2 percent of bad reactions are caused by improper use of antibiotics."

Not to mention the impact of all those antibiotics on drug resistance.

2005-12-29T10:51:00.000-05:00

Alcoholism Drug Still Awaits Final Approval

Vivitrol, known as Vivitrex while it was being tested, is an injectable, extended-release version of naltrexone, a now-generic pill that's prescribed to alcoholics to discourage them from resuming drinking. The once-a-month injection of Vivitrol will be marketed as a way to improve patient compliance over the once-a-day naltrexone pill.

I didn't know about this drug before I saw this article. I have never used naltrexone for alcoholics and the articles I have read since comment that most doctors either don't know about it or don't use it because of poor compliance. This monthly injection may change that. Especially if the courts order its use in connection with DUI, domestic violence, etc.

More

In the placebo group, the median number of heavy drinking days was reduced from 19 days per month in the month prior to the study (baseline) to six days per month over the six-months of placebo treatment. The placebo group received treatment consistent of placebo injection, monthly medical attention and counseling.

The Vivitrex treatment group showed a 48% further reduction in heavy drinking over the placebo group. Over the six-month treatment period, the median number of heavy drinking days was reduced from 19 days at baseline to three days per month in the Vivitex group compare to six days per month in the placebo group.

2005-12-28T10:22:00.000-05:00

Amazon is amazing. I bought one of these today for a friend.

2005-12-28T08:58:00.000-05:00

The hospital where I work was independent until it was bought out, recently, by a large corporation. The corp has described plans to enlarge the hospital with expanded ICU space, a heart surgery center and to close a nearby hospital owned by the same corp. They have already begun to shift some of the inpatient load. This is concerning to those of us who work in the ER, as we already have a significant problem with bed availability. Any ER docs out there without this complaint?

It is not unusual for us to have a patient remain in the ER several hours after admission, waiting for "the room to be cleaned." Aside from the passive tense of that comment, we have some concern that room assignments are shifted to keep the patient off the floor, at least until shift change.

That makes this article that much more concerning. Maybe we can use this data in discussions with nursing administration:

The potential for errors being made during long patient stays in emergency rooms is among the medical dangers that will be studied through grants awarded to 10 doctors by the malpractice insurer for Harvard-affiliated hospitals.

Emergency room ''boarding" -- when patients are examined, treated, and admitted to a hospital, but kept waiting for a room -- is fraught with risk, said Dr. Shan Liu, an emergency-room doctor at Massachusetts General Hospital and a student at the Harvard School of Public Health.

2005-12-28T08:51:00.000-05:00

As bad as it seems for us, other professionals have malpractice problems as well.

In its most recent study of claims experience, from its more than 7,000 accounting professional clients in 44 states, the Redwood City, Calif.-based insurer has found tax work accounts for the most claims filed and the highest total dollar volume of damages sought. Camico is second, behind a program sponsored by the American Institute of CPAs (AICPA), among the profession’s most prominent professional liability insurance carriers.

Tax ranks highest among the service areas generating claims because it is among the services accounting professionals are most likely to offer and its technicalities can mean a minefield of risks. The technical nature of tax work “places most of the burden for decision-making on the CPA (s),” who at the same time “are limited in what they can ask clients,” says Ron Klein, Camico’s vice president of claims.

“It's much like a patient seeing a doctor about a serious, complex medical condition; the problem and treatment are so critical that the patient will ultimately go with the treatment the doctor recommends.” he adds.

Following tax on the list of leading areas for generating claims are, in respective order: financial statements, investment fraud and defalcation. Within tax work, technical income tax issues are the primary area of loss, followed by S and C corporation elections and estate planning.

2005-12-28T08:41:00.000-05:00

Primer for politicians (page 1): Talk a lot about ethics. The ~~suckers~~ voters like to hear about ethics. If you go so far as to form a committee, be sure not to give it any real power, like subpoena or investigate powers. Better yet, make sure that the committee only meets when you ask for advice. That way, you don't ever have to convene the committee. If you actually name members, make sure they are ~~all your cronies~~ like-minded in their dedication to ethics.

Special ethics panel has never met

Three-year lull calls into question Bredesen's commitment, some say.

In the months after Gov. Phil Bredesen's inauguration, he talked big about ethics and about fairness, signing a series of executive orders that created a special ethics committee and a panel to ensure that state workers are promoted properly.

"One thing I want to do is return a higher degree of confidence to people in state government," Bredesen said at a February 2003 Cabinet meeting as he signed executive orders that would create what he called "the toughest ethics policy in the history of Tennessee."

But if the talk was big, the action was little, if any. The governor's special ethics committee, created in that Cabinet meeting, did not meet even once.

And the panel he created in October 2003 to ensure that the state promotions process was conducted fairly never met, either.

Now, after the Department of Safety's top leadership has been swept away in an ethics scandal over deep-seated cronyism in the Tennessee Highway Patrol, and with the governor's closest aide beset by his own ethics issues, some have started asking questions about why the governor has let these panels languish.

"I was bothered then," said printing company owner Gary Marlar of Nashville, who has begun following ethics issues since Bredesen took office. "Now, I feel I've been smacked in the face."

The reason that at least the governor's ethics committee never convened is "there have been no issues that have risen to the level that would require a recommendation from this body," Bredesen spokeswoman Lydia Lenker said. "Any issues that have come before the governor, he has dealt with quickly and with a firm hand."

The governor's critics say that the committee to examine hiring and promotions created by Bredesen in October 2003 might have uncovered cronyism in the Highway Patrol. A Tennessean investigation published last month showed that two-thirds of THP promotions under Bredesen's administration went to officers who gave money to his campaign, or had family members or political patrons who did.

More than half in that group were promoted even though they were competing against officers with higher promotion scores.

This panel "is advisory only," said Lenker, who confirmed that no one was ever appointed to the board. "It is not charged with any investigatory powers. As a part of our review of all boards and commissions, we have taken a look at this board to see if its functions are duplicative of other state boards, commissions and agencies. It is currently under review."

After Operation Tennessee Waltz, when federal agents arrested four sitting legislators in a bribery and extortion sting, Bredesen came alive on all things ethical. He began planning a special session on ethics. He put together a citizens panel that was to generate ideas on how to rein in a legislature perceived as greedy and out of control. The governor also put out his own ideas on what might be done.

The committee charged with overseeing fairness in hiring and promotion deals chiefly with fairness as it relates to race, gender and sexual orientation — and the Bredesen administration has never been accused of unfairness as it relates to those issues.

But some are seeing those efforts in a new light, with the realization that Bredesen's first big announcement on ethics just after he took office was followed by very little action. That has some legislators raising questions as they are about to embark on a special session on ethics that Bredesen himself called.

State Rep. Donna Rowland, R-Murfreesboro, said she was suspicious that Bredesen created the committees and never followed through. "I am not aware that those committees have even been established," Rowland said. "Why are they not being used for these investigations as step No. 1?"

And Rep. Glen Casada, R-College Park, said that it appeared there may be exceptions to the ethics rules for those closest to the governor.

"Like most Tennesseans, I thought you would treat your political appointees in the same manner as all state employees are treated," Casada said in a letter he wrote to Bredesen last week. "It now appears that friends of the Governor get special treatment."

2005-12-27T17:20:00.000-05:00

THP urges safe driving during holidays

At other times, drive however you please.

Official notice from Visit Tennessee, Inc.

2005-12-27T17:15:00.000-05:00

FDA OKs STAAR's optical implant

The Food and Drug Administration has approved a surgically implantable lens designed to treat nearsightedness, giving myopic adults another alternative to eyeglasses or Lasik surgery, STAAR Surgical Co. said Friday.

The news sent Monrovia-based STAAR's stock soaring. Shares were up $2.74 to close at $8.51 Friday on the Nasdaq Stock Market.

The Myopic VISIAN ICL is profitable on the international market, but the company loses money in the United States, said David Bailey, chief executive officer and president of STAAR Surgical. "This launch is the fastest route to profitability in the U.S.," he said.

The ICL is approved for sale in 41 countries. It has successfully been implanted in more than 40,000 eyes worldwide, the company said.

It will join on the market another implantable lens, the Artisan, made by the Dutch company Ophtec B.V. and approved by the FDA in 2004.

The lens is placed behind the iris and is invisible when in position, Bailey said. It's a permanent correction, but it can be removed if needed, he said.

The procedure appeals to those unsuitable for laser treatment, such as people with dry eyes or high levels of myopia, Bailey said.

2005-12-27T17:08:00.000-05:00

FDA: Barley Products Can Claim Heart Benefits

Cereals, breads and other products containing whole or milled barley grain can now claim to reduce the risk of heart disease, U.S. health officials said Friday.

The U.S. Food and Drug Administration's ruling allows companies to immediately begin advertising the benefit on their product packages, which many food makers hope will help boost consumer sales. To qualify, barley-containing foods must provide at least 0.75 grams of soluble fiber per serving, the agency said.

Barley is a cereal grain grown mostly in the western United States, as well as in Australia, Canada and other countries, according to the National Barley Foods Council, which first petitioned the FDA for the decision in 2003. While much of the crop is used for animal feed and beer, people can cook pearl barley as a rice-like dish. Barley flour and grains are also used in baking and in cereal.

Like other grains, barley contains fiber that health experts say can help reduce the risk of coronary heart disease, which can restrict blood flow and lead to chest pain and heart attacks. About 13 million Americans are diagnosed with the condition, according to the American Heart Association.

2005-12-27T12:10:00.000-05:00

An interview of AR by ST.

AR is a 14 year-old girl who was brought to the ER by EMS after the Sheriff's Drug Task Force raided a home with a meth lab. ST is a counselor with Child Protective Services.

ST: Do you know why you are here?

AR: My mother was arrested and the cops said I had to come here.

ST: Do you know why your mother was arrested?

AR: The cops say she was making meth.

ST: Was she?

AR: My mom said to keep my mouth shut.

ST: What we discuss today is going to be used to help you, not to hurt your mother. I need to know what chemicals you may have been around.

AR: I don't know what kind of stuff I been around. Lots of stuff.

ST: Do you feel safe at home?

AR: I guess I do. But I been worried about my Sissy and Bubba.

ST: How old are they?

AR: Sissy is 10 and Bubba is 3.

ST: What are you worried about?

AR: Well, them chemicals you talked about. And the people that come over.

ST: What about the people?

AR: They always have guns. My momma has a rule that you have to leave you guns and knives at the door. There's always a big pile on the floor at the front.

ST: Do you touch them?

AR: No. But Bubba got 'hold of one once. A gun, I mean. I don't know what kind. But Sissy and me had come out to clean and found him in the front hall waving a gun around. He wouldna shot it, I mean he don't know how. But we were afraid of an accident. Sissy and me was real scared until we got it from him.

ST: Why didn't you get your mother?

AR: She was asleep and we couldn't wake her up.

ST: How often did your mother have people over?

AR: Oh, there was people over all the time. But sometimes she would have these parties and lots of people would come over. The would use drugs and drink and have sex. Everybody would end up naked on the floor of the living room.

ST: And you and your brother and sister were part of this?

AR: No, ma'am. I mean, we would watch TV in momma's room. When everything would get quiet, me and Sissy would come out and pick up all the needles so as Bubba wouldn't get into them. That was scary.

ST: Scary?

AR: Yeah. You know you can get sick from them needles. That's why we can't let Bubba get ahold of 'em.

There was more, but you get the drift. These kids come into the ER in incredibly filthy clothes, malnourished and having been exposed to toxic waste, not to mention the clouds of smoke around the house from the people smoking meth. As this interview demonstrates, they are also exposed to sex and weapons, often to great detriment.

I am sick and tired of advocates for legalizing drugs claiming that this doesn't hurt anyone other than the user. These kids are behind the 8 ball. Look at the example that has been set for them. This environment was not created because the drug was illegal, but because of the way the drug makes people act.

UPDATE:
Advocates for legalizing drug use, such as those in the comments, ignore the realities of use of mood altering drugs. The mother described in this interview did not behave the way she did because the drugs were illegal, but because they were available and for the effect. I agree that the kids would not be exposed to some of the chemicals if the drugs were manufactured legally and sold OTC, but the neglect, malnourishment and exposure to needles, guns and sex would still be present.

2005-12-27T11:30:00.000-05:00

Go forth and read Grand Rounds. Then come back here, of course.

2005-12-26T14:53:00.000-05:00

Via Instapundit, Global Polio Largely Fading:

The 17-year effort to eradicate polio from the world appears to be back on track after nearly unraveling in the past three years.

A new strategy of using a vaccine targeting the dominant strain of the virus appears to have eliminated polio from Egypt, one of six countries where it was freely circulating. That approach is on the verge of doing the same in India. Twenty-five years ago, India had 200,000 cases of paralytic polio a year. A decade ago, it was still seeing 75,000 cases annually. Through November this year, it recorded 52.

Such dramatic successes, many the result of a more potent formulation of polio vaccine, have once again made eradication of the paralyzing viral disease a realistic goal. Only one human disease -- smallpox -- has ever been wiped out, and that was almost three decades ago.

From 7500 to 52. Wow. So immunizations actually work. I agree with Professor Reynolds that the anti-immunization hysteria has slowed this process.

2005-12-24T11:15:00.000-05:00

Mad House Top 10 of 2005: (as chosen by the Mad House Madman)

Disproven medical treatments for 2004 via RangelMD

The physician as detective

2005-12-24T00:26:00.000-05:00

A leading med-blogger, Medpundit, writes:

This time of year, I always see a sharp increase in patients who are suffering emotionally. Whatever it is - too much togetherness, too many unmet expectations, financial stress, temporal stress - the week before Christmas my practice sees an influx of depression and anxiety. And always - always - the final office day before Christmas, someone comes in threatening suicide. Do you know how hard it is to find a psychiatrist on the last day of the week before Christmas? As hard as it is to convince a suicidal patient to go to the emergency room for a psychiatric evaluation and admission.

Interesting comments regarding suicide, as well, from inteuri:

Psychiatry residents need reminders that suicide is not normal. We frequently talk to people who have attempted suicide and after a while, we become cavalier about the whole affair. We forget about all of the potential pain and uncomfortable emotions that formed the foundations of the attempts and instead, crank through these suicide evaluations as if we were running through a checklist of things to pack on a trip. It becomes an “us” versus “them” issue. And we start to feel annoyed that yet another person had tried to overdose on some medication….

I worry more about the people who hurt themselves and then deny suicidal ideation in the ER. I mean, come on, if you really want to kill yourself and you know that telling the ER doc that's what you want to do will get you locked away, wouldn't you say, "No, Doc, I don't want to die. I just did this for attention. The knife just slipped."

When I was working at Mercy Hospital in San Diego on the trauma team, I had a patient who had jumped of an overpass onto a very busy street. Miraculously, the fall didn't kill her and none of the cars hit her. She did suffer multiple spinal compression fractures, fractures of both femurs and calcanei and assorted other injuries. One morning I walked into the neurosurgical ICU (on the 10th floor) and saw her with her eyes deviated up and to the left. I was worried about a bleed and called her name. She rolled her eyes toward me and said good morning. Relieved, I asked her what she was doing. She answered that she was looking at a window, wondering if it would open. This was SERIOUS suicidal intent. Even with her level of injury, she was still trying to find a way to die.

I pray for her and others like her.

2005-12-23T13:13:00.000-05:00

Of course, this is a good idea.

The FDA has approved the first West Nile Virus blood test to screen donors of blood, organs, cells, and tissues.

“This new test will help protect patients who receive blood and other such products against West Nile infection,” states the FDA in a news release. The test checks for viral genetic material.

To date, there have been 30 documented cases of people who most likely acquired West Nile virus from a blood transfusion, including nine who died.

2005-12-22T21:02:00.000-05:00

From the comments on this post at GruntDoc (doesn't his blog look great?):

My wife, a fellow emergency physician here at Landstuhl Regional Medical Center (Germany), had a 30yo male with classic signs for appendicitis (i.e. RLQ pain, RLQ ttp, rebound, guarding) a few nights ago. After completing her Hx and PE she called the SOD (surgeon of the day) for a consult stating that she believed her patient had an acute appendicitis that required surgical intervention. The surgeon, of course, asked her what the CBC and UA results were... She stated that they were still pending.

The SOD went off on her questioning her reasoning for a surgical consult without the benefit of laboratory results... Taking the high road she calmly stated that the labs were pending and would be resulted shortly after his arrival to the ED. Upon his arrival he berated her in front of the entire ED staff for a premature consult. Again, taking the high road, she thanked him for arriving in the ED so quickly and directed him to the patient's bedside. Moments after examining the patient he filled out a buck slip and took the patient to the OR for his appendectomy -- the labs were still pending as he wheeled the patient to the OR...

Unfortunately, our surgeons sometimes ask for the CT results and castigate us if we haven't done one. I can't keep track of who wants one and who doesn't. What bothers me the most is that we (the ER docs) can predict, based on the time of day, whether a particular surgeon will ask for a CT. If it is almost time for the doc we call to go off call, the chances are high we will be asked to order a CT. If it is 5am, we will be asked for a CT. If we get a CT in the evening and end up delaying the call to the surgeon until, say, midnight, we will be asked why we got the CT.

Follow the link to find out the results of the surgery.

2005-12-22T18:43:00.000-05:00

The information regarding the use of levonorgestrel for "emergency contraception" is conflicting and is spun by advocates/opponents. Even the use of this phrase ignores the possibility that fertilization would have occured by the time the pill is taken, and the pill works by preventing implantation. Opponents point out that this is abortion, not contraception.

Some authors have tried to redefine the beginning of a pregnancy as when implantation occurs, not fertilization. However, basic biology defines the creation of a new organism at the time of fertilization.

"Fertilization is a sequence of events that begins with the contact of a sperm (spermatozoon) with a secondary oocyte (ovum) and ends with the fusion of their pronuclei ... and the mingling of their chromosomes to form a new cell. This fertilized ovum, known as a zygote, is a large diploid cell that is the beginning ... of a human being." (Moore, Keith L., Essentials of Human Embryology. Toronto: B.C. Decker, Inc., 1988, p.2.) "Although human life is a continuous process, fertilization is a critical landmark because, under ordinary circumstances, a new, genetically distinct human organism is thereby formed. ... The combination of 23 chromosomes present in each pronucleus results in 46 chromosomes in the zygote. Thus the diploid number is restored and the embryonic genome is formed. The embryo now exists as a genetic unity." (O'Rahilly, Ronan and Müller, Fabiola. Human Embryology and Teratology, 2nd edition. New York: Wiley-Liss, 1996, pp. 8, 29). "Almost all higher animals start their lives from a single cell, the fertilized ovum (zygote). ... The time of fertilization represents the starting point in the life history, or ontogeny, of the individual." (Carlson, Bruce M., Patten's Foundations of Embryology, 6th edition. New York: McGraw-Hill, 1996, p.3.) "Embryo: An organism in the earliest stage of development; in a man, from the time of conception to the end of the second month in the uterus." (Dox, Ida G. et al. The Harper Collins Illustrated Medical Dictionary. New York: Harper Perennial, 1993, p. 146.) "The fertilized egg, now properly called an embryo, must make its way to the uterus." (Carlson, Bruce M., Human Embryology and Developmental Biology. St. Louis: Mosby, 1994, p.3).

Many are advocating the clearance of the "Morning After Pill" to be sold OTC. Many of those same people are critical of the FDA for delaying this approval. I can't imagine why the FDA would consider approving MAP for sale OTC if politics were out of the picture. The only reason to sell MAP OTC is related to "women's rights" and is a political issue. What other hormonal medication is sold OTC? Why aren't regular OCP's sold OTC? How do the propronents think these can be kept from girls under whatever age they think is politically palatable?

Why do so many argue that MAP is not an abortofacient? Obviously they want to ignore the issue of abortion. Ignoring this issue is a political issue. They know the debate would be much broader if this issue were included.

Opponents argue that making MAP easily available would increase the rate of STD's by decreasing the incentive to use condoms. If your primary reason for using a condom is contraception, this would make sense. Why use a condom when you can just pop a pill after sex and prevent pregnancy? OTOH, I hope we are educating people about the risk of STD and the need for barrier methods (or my recommendation, abstinence).

UPDATE:
In response to a question in the comments about anti-implantation vs anti-ovulation, the company that manufactures Preven, Roberts Pharmaceutical, stated, "more often it would prevent implantation."

Jennifer Kessell, spokeswoman for Roberts Pharmaceuticals, the Oakville, Ont., Canadian manufacturer of the drug, sells Preven as though it were a new shade of eyeliner. "They're not sure of the ins and outs of it," she says. "But it's thought to work two main ways." First, by delaying ovulation, and second, by preventing implantation of a fertilized egg into the women's uterus. More often it would prevent implantation, she confirms. Ms. Kessell offers Preven as an alternative to abortion which "ends the life that is already implanted." She also calls it "emergency contraception" that prevents pregnancy.

But isn't Preven for women who believe they are already pregnant? Is this a new definition of pregnancy? "There's different definitions [of pregnancy] depending on where you live," offers Ms. Kessell. "Most doctors would say pregnancy begins at implantation," she continues. Only "anti- abortionists" would say life begins "when the sperm meets the egg. Period." Pregnancy begins when a woman is "comfortable" with it beginning, she adds . "It depends on your own personal views and what you want to believe."

Pro-abortion groups have tried to redefine pregnancy as beginning with implantation, not with contraception. I don't know any physicians who hold this view. Of course, this view would be very convenient for those who don't want to have the drug labelled as an abortofacient. The quotes above should clearly indicate the scientific falacy of this viewpoint.

2005-12-22T18:20:00.000-05:00

Why are so many people worried about change? Why are the animal rights folks so worried about species going extinct? What's so bad about global warming?

Do these people think the world would be better off if the climate was exactly the same as it was a million years ago? Five million years?

What if no species had ever gone extinct?

Of course things have to change. Medicine has changed noticeably since I graduated medical school and that wasn't that long ago. We cure diseases now that would have killed patients even 20 years ago. The average lifespan is much longer now that 100 years ago.

I don't think I would enjoy the beach during the ice age as much as I do now that there has been some global warming.

Who knows what kind of awesome life forms might develop if we killed off a few species that would have eaten them and warm the place a few degrees?

2005-12-22T18:13:00.000-05:00

Polar Wrap's ToastyFeet with Aerogels nanotechnology

Polar Wrap launching ToastyFeet insole liners using patented nanotechnology from Aspen Aerogels to protect feet from sever cold and help to get rid from heavy shocks.

In fact, ToastyFeet just might protect you from cold symptoms.
As reported by Reuters on November 14th, British researchers claimed that exposing bare feet to cold water for 20 minutes increases a person's chance of getting cold symptoms.

The researchers said that cold feet cause a constriction to blood vessels in the nose which can aid the cold virus, according to Reuters.

'It's clear that to keep from getting a cold, you need to keep your feet warm,' said McCormick.

'In the winter, it often feels like you're standing on ice.

That's because the soles of your shoes or boots are where your feet need to be protected from the cold the most.'

But why isn't your footwear keeping out all of the cold?
'Because most insulation requires loft -- like the loft in a cotton ball or fiberglass house insulation,' said Marc Lebel, Vice President of Aspen Aerogels, 'but when you step on it, it gets compressed and loses its loft and therefore its insulating power.'

But Aspen Aerogels' insulation doesn't require loft.

Its structure contains nanometer-sized pockets of air that can maintain thermal protection and shape even when you step on it.

In partnership with NASA, this same flexible aerogel technology is being developed for next generation space suits.

2005-12-21T09:04:00.000-05:00

I am honored to have been invited to guest blog at KevinMD. Go there to see what I have to say and to browse some of the other guest bloggers.

2005-12-16T14:14:00.000-05:00

Listening to lung sounds is such a variable experience. So many people talk to you while you have the stethescope in your ears, moan/groan/hum while breathing or even hold their breath. A lot of the time, they will take a deep breath and hold it. Or breath so slowly that you can't hear anything.

I have developed a habit of saying, "OK, can you take a deep breath, in and out." Sometimes I have to say, "Don't hold your breath, just breath in and out."

Just now, a patient was humming I Wish You a Merry Christmas while I was trying to listen. Good humming, though.

2005-12-15T18:27:00.000-05:00

CostRx: High premiums killing specialties

The first installment of CostRx features an interview with Washington-based neurosurgeon David Curfman on how skyrocketing medical malpractice insurance premiums are driving up the cost of healthcare and driving doctors out of the profession.

Q. On the topic of soaring medical malpractice premiums, you have stated that, if something isn't done about the problem in the next five to 10 years, we will have a real crisis on our hands. Can you explain?

A. Well, I think it's going to be sooner then another decade. I very strongly believe that it's already an evolution. In probably the last three or four years, it's gotten fairly severe. My prediction in 2002 -- I gave a talk on this -- was that I thought both neurosurgery and obstetrics were going to collapse by roughly around 2009 or maybe 2010.

Q. Can you define what you mean when you say "collapse?"

A. What I mean by that is that a good portion of the people in the field who are remaining by then, those who are still paying the huge amount on a premium for malpractice insurance, their overhead is going to exceed their income to the point that there's no way that they can stay in business. In fact, there are many neurosurgeons -- and the same applies to obstetrics -- that, unless you dramatically change your profession from one of either solo practitioner (or) private practice -- in other words, non-institutional -- you're not going to be able to survive.

The few who have changed their practice have gone on to be part of a big HMO or have sequestered themselves in a government facility (like) a veterans hospital, or have gone with some hospitals where they're actually hiring neurosurgeons and obstetricians to do the work that they would have never have done as recently as five years ago. ... This is a crisis of major proportion that's hitting the big hospitals in the big cities -- inner cities -- that are faced with a lot of people who have no insurance or have very, very meager coverage on a Medicaid policy.

2005-12-15T11:46:00.000-05:00

You have to be very careful giving meds to pregnant women. Like this:

The Food and Drug Administration has warned pregnant women and their doctors away from the anti-depressant Paxil because of an increased risk of heart defects in newborns.

With the warning, the agency for the first time placed a popular anti-depressant — one in the same drug class as Prozac and Zoloft — into its second-highest category for risk of birth defects.

2005-12-15T11:34:00.000-05:00

In a comment below, Michelle wrote:

hi, i need your help in doing a survey about blogging for my Master's thesis. Would it be alright for you to give me your email so i can send to you? Your help would greatly aid my thesis.

Michelle, my e-mail address is in the sidebar to the right. It is 8drtony 8at 8drtony.biz Leave off the spaces and 8's.

Feel free to write to me. If you would like to put your e-mail in the comment section of this post, perhaps other bloggers would write to you, also.

2005-12-14T13:55:00.000-05:00

Bredesen is right to clean house at THP

Let the housecleaning begin at the Tennessee Highway Patrol. The more we learn about the behind the scenes operation of THP, the worse the whole mess looks. While the THP scandal didn't begin with the administration of Gov. Phil Bredesen, he has promised to end it.

For decades, THP has been as much a political operation as it has been a law enforcement operation. That has earned THP officers and officials some nice perks. There is a host of special rules that apply to THP officers that few others in state government benefit from. Everything from special pay raises to the politics of promotions within the department is now coming under intense scrutiny.

So Governor Bredesen want to hire a consulting firm to do advise on the housecleaning:

Nicely, Finance Commissioner Dave Goetz and Deputy Personnel Commissioner Nat Johnson told the panel that plans are under way to hire Kroll Government Services Inc., a New York-based security consulting firm, to conduct a review of Highway Patrol practices.

But the estimated $100,000 to $200,000 contract is a no-bid contract because of the need to act quickly:

Sens. Rosalind Kurita, D-Clarksville, and Jerry Cooper, D-Morrison, questioned the plan to sign up Kroll without a competitive bidding process. Goetz said the paperwork for that would take "six to eight weeks." He said the administration wants to move forward quickly.

The problem is, the firm for which the no-bid contract is proposed has ties to the Bredesen campaign:

Michael Shmerling, a former Nashville businessman who is listed on the company Web site as head of another Kroll division, has donated at least $7,500 to Bredesen's campaigns since 2001, a review of finance disclosure records after the meeting indicated.

I can understand the need to hire a consulting firm and also the need to award a no-bid contract, in the interest of expediency, but wouldn't it be better if the contract went to a company whose officers had not contributed to the governor's campaign.

This sounds like the criticism of the Bush administration for no-bidding the work they gave Halliburton in Iraq. However, this article doesn't describe that Kroll is in a unique position, as Halliburton was.

2005-12-14T13:50:00.000-05:00

Interesting.

Medical malpractice insurance companies have started turning a profit in West Virginia since the Legislature passed several rounds of limits on malpractice lawsuits, state Insurance Commissioner Jane Cline told lawmakers Sunday.
...
With insurers doing better in the Mountain State than the national average, Cline said that in the past year, at least three companies have sought to reduce the rates they charge doctors.

Sort of puts a lie to the claim that malpractice tort reform didn't affect insurance rates, doesn't it.

2005-12-14T11:25:00.000-05:00

I just wrote an order for "Vit B12 1mg IM weakly."

2005-12-14T10:12:00.000-05:00

Europe Botching Afghanistan Duties

A very interesting look at the role of the "Great" European countries in Afghanistan.

I have an idea. Let's really get France involved. We should convince them to be trainers for the insurgency. This would get them out of our hair, make them happy doing something to oppose, decrease military readiness of the insurgency and, best of all, support our textile industry.

After all, somebody has to supply all those white flags they will be needing. Perhaps they could give them out in lieu of diplomas as the insurgents graduate training.

2005-12-14T09:54:00.000-05:00

Another try at a rotavirus vaccine. What a boon this would be if it doesn't cause problems.

A new vaccine against a sometimes deadly diarrheal infection in infants does not appear to cause the problems associated with an earlier vaccine, though the government says it needs more information.

A Food and Drug Administration reviewer wrote that RotaTeq, drug company Merck & Co.'s vaccine against rotavirus, is "highly likely" to be effective based on the results of a study that showed a decrease in rotavirus-caused illness.

2005-12-12T13:37:00.000-05:00

Would you die to save the life of your child? Most of us would reply, "In a heartbeat!" So why would this be such a surprise? (HT KevinMD)

2005-12-08T22:18:00.000-05:00

OK, Greg, this is pretty funny.

2005-12-08T18:35:00.000-05:00

This is scary. Especially as my hospital is about to introduce a new computer system.

When I was in the Navy, we used a system called CHCS. The system had the capacity for the physicians to enter orders on inpatients, but this wasn't used. Basically, so many docs refused to do it that it became impractical.

What we did use was the prescription entry function. This shifted the work of entering the prescription into the computer from a pharmacy tech to the physician.

It had several good points, though. The system would prompt you with the proper dosage and you couldn't write for something that wasn't available or in a preparation that wasn't available. You couldn't write for a drug that wasn't carried in your local pharmacy which meant you didn't get a phone call later. You couldn't order Amoxil 550mg for example.

You could put together drug sets and just type in the name of the set. You could create sets of meds based on weight. You type in a kid's weight and it offered you a list of pediatric meds with the correct dosages already calculated.

Putting together sets of inpatient orders could be useful. You would be prompted with orders based on EBM and the computer could help you with the intensity of service and severity of illness necessary to get paid, or get the hospital paid.

2005-12-08T18:15:00.000-05:00

Step 1: Get Nationalized Health Care

Step 2: By limiting resources (you have to do this, you cant' afford anything else) you informally begin rationing health care. People die while waiting for care.

Step 3: Introduce rationing of health care in a potentially palatable way. Blame it on the patient.

Step 4: Formalize rationing of health care through legislation.

Step 5: Discontinue health care benefits for those who are "too old." Why waste the money?

Step 6: "Allow" euthanasia.

Step 7: "Encourage" euthanasia. As in "Don't you want to do your part for your descendants?"

Step 8: Legislate euthanasia. I mean, didn't you see the movie?

2005-12-08T13:21:00.000-05:00

If medical treatment were covered by the mainstream media:

MILLIONS OF INNOCENTS SLAUGHTERED

In an exclusive interview, we have obtained this information from a certain E. coli.

Incredibly, Mr. coli has survived a recent, unprovoked attack by government approved forces. Attacking in overwhelming numbers, the agents, known as "white cells" destroyed Mr. coli's entire community.

The details are staggering. "All we wanted was to survive," Mr. coli relates regarding his friends, family members and others in the community. "We were just hanging around, dividing, you know, for survival of the species, when the attackers swept in. No mercy. We were all targeted."

Fortunate to have mutated at the last minute, Mr. coli was the only survivor. "I was lucky to get out. Those white cells were inhuman. I saw them eating other coli's whole."

“And don’t get me started on calling them ‘white cells.’ These cells greatly outnumber the downtrodden bacteria. Our minority status is being ignored. I demand that the administration immediately give me nutrients as reparation.” These remarks were submitted as part of a package of prepared comments by the Reverend Gimme More, of the Church of the Feculent.

Unnamed sources high in the government have verified that it is government policy to use overwhelming force and try to destroy any bacteria immediately upon detection. This policy does not take into account the rights of the bacteria and doesn't allow for due process.

"No Geneva Protocols are observed," according to our source. "The Attorney General has advised that we should follow a 'take no prisoners' approach."

Kleb Siella, a spokesman for the Bringing U Global Sickness, or BUGS, has details of the use of Weapons of Mass Destruction. "I have personally seen white blood cells release chemical weapons in the vicinity of newly divided cells. These babies were eaten away by the chemicals they call 'enzymes.'"

We have uncovered details that, high up in the thalamus, the President and his staff are plotting to use thermal weapons! President M. O. Ron reportedly told his Secretary of Defense, Luke O. Cyte, to try raising the temperature in an attempt to cook these helpless, harmless residents. Critics, being much smarter, have pointed out that this is a violation of the Kyoto treaty.

Of course, this is proof positive that the administration is responsible for global warming.

Stated Mr. Siella, "The position that these are invaders is preposterous. That is just more bias against immigrants from a hostile administration."

Claiming to have formed a coalition, Secretary of State Chemo Tactic has attempted to attract others to join this blatantly illegal attack against residents in our body. Some have said that Secretary of Nutrition, Pan Creaz, has informed the muscles that she will withhold glucose if they don't immediately begin shivering. This action will result in raised temperatures, a maneuver that has been criticized by foreign leaders such as President Jacque Pneumococcus. "We won't participate in this illegal action," President Pneumococcus stated forcefully.

“Whenever he speaks, I just get lightheaded and short of breath,” stated Senator Diz Pnea, wife of the former president. “He is so handsome. I would believe him over our selected/not elected President M. O. Ron anyway. Don’t you just love that accent?”

Additional opposition has come from Senator Ima P. Nis. “When I was visited by Gon O. Rhea, I just sat back and enjoyed it. Why is he so angry? These bacteria have a right to live, too. And I look French and served in Vaginanam,” added the former candidate for the presidency, who would have won, had not his opponent caused premature division of some cells in the colon and co-opted their votes. "Besides, I voted for it before I voted against it."

You may recall, because we write about it 3 times every day, that Senator Nis is a decorated war hero, having served in Vaginanam for 30 minutes. Others have criticized his service, saying it was only 60 seconds, but Senator Nis is quick to point out that he was withdrawn prematurely and that his opponents don’t even know the difference between two inches and six inches.

None other that the mighty Secretary General of the United Nosepickers, the UN, has labeled the current slaughter “germicide.” Secretary A. Nus has vowed to bring charges in the International Court of the Hepata for this illegal, unilateral action.

National Security Advisor Andy Biotic denied that this action was illegal or unilateral. He pointed to resolutions by the Cortex authorizing the use of force for defense of the corpus. He listed other coalition members, such as Mucus, Cilia and T-Cells.

But everybody knows he’s a liar with ties to multiple drug companies.

Former CEO of Ortho-McNeil, Vice-President Leva Quinn continues to refuse access to records of his (probably illegal) “Immune System” committee meetings. These meeting were held in the Thymus during the first term.

2005-11-30T16:30:00.000-05:00

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.

2005-11-30T14:39:00.000-05:00

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.

2005-11-29T18:18:00.000-05:00

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.

2005-11-28T16:09:00.000-05:00

That Karl Rove, what will he think of next?

2005-11-28T16:00:00.000-05:00

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.

2005-11-27T17:16:00.000-05:00

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.

2005-11-27T17:12:00.000-05:00

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.

2005-11-27T16:52:00.000-05:00

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.

2005-11-27T16:44:00.000-05:00

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.

2005-11-27T16:41:00.000-05:00

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.

2005-11-27T16:27:00.000-05:00

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.

2005-11-12T13:16:00.000-05:00

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."

2005-11-11T15:49:00.000-05:00

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.

2005-11-07T22:41:00.000-05:00

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.

2005-11-07T21:29:00.000-05:00

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.

2005-11-06T11:39:00.000-05:00

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

2005-11-01T08:51:00.000-05:00

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.