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Archive for January, 2013

Tuesday, January 29th 2013

More Implications For Health In Obesity

Obesity is a relative risk for death in a motor vehicle accident. A matched cohort retrospective review from NHTSA FARS database was published in the Emergency Medicine Journal recently. In summary,

Its findings show those who were most obese, with a Body Mass Index (BMI) of 40 or over, were 80% more likely to die in an accident than drivers of a healthy weight.

[...]

The research, published in the Emergency Medicine Journal, found that fat people are propelled further forward during a collision because their additional soft tissue prevents the seat belt tightening immediately against their pelvic bones.

As if some needed more data as encouragement to maintain a healthy weight.

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Monday, January 28th 2013

More For Regulation

As the first of trials are set to begin for Depuy’s ASR scandalous hip implant, the medical device failure is back in the mainstream news. I had previously commented on how the staggering of recalls of the hip implant – Johnson & Johnson continued to sell the hip in some jurisdictions while recalling it in others – called for better international communication and a leveling of enforcement activities. A pretty remarkable reconsideration of my libertarian ideals. I’ll try to refrain from the fanaticism of calling for more protection from the government despite this,

An internal analysis conducted by Johnson & Johnson in 2011 not long after it recalled a troubled hip implant estimated that the all-metal device would fail within five years in nearly 40 percent of patients who received it, newly disclosed court records show.

Johnson & Johnson never released those projections for the device, the Articular Surface Replacement, or A.S.R., which the company recalled in mid-2010. But at the same time that the medical products giant was performing that analysis, it was publicly playing down similar findings from a British implant registry about the device’s early failure rate.

Certainly, what is known publicly, is call for compensation to those who received the implant and civil punishment for Johnson & Johnson.

Monday, January 28th 2013

You Are Going To Die

Sometimes the New York Times puts out poignant opinion pieces. Often these are essays of Tim Kreider. Indeed, his piece, The ‘Busy’ Trap, is amongst the most on the nose things I’ve ever read. But this is about something more pertinent to this blog. Last week The New York Times published this,

Segregating the old and the sick enables a fantasy, as baseless as the fantasy of capitalism’s endless expansion, of youth and health as eternal, in which old age can seem to be an inexplicably bad lifestyle choice, like eating junk food or buying a minivan, that you can avoid if you’re well-educated or hip enough. So that when through absolutely no fault of your own your eyesight begins to blur and you can no longer eat whatever you want without consequence and the hangovers start lasting for days, you feel somehow ripped off, lied to. Aging feels grotesquely unfair. As if there ought to be someone to sue.

It is well worth a read.

Saturday, January 12th 2013

Culturally Competent Care In A Rush

Providing culturally nuanced medical care is held up, sometimes, as a right of patients and a goal that should be paramount in medical care; even with all else that needs attention. Sometimes the emphasis on culturally component care is stressed to a laughable degree. As if a physician practice, without a significant east African patient population, should have immediate access to an in person female Somali speaker, of the same dialect as the patient,

Though the state requires all medical providers to offer translation, current services fall short. Most rely on special phone lines for translation, which are based out of state and offer little control over the gender (Muslim women prefer female translators) and dialect of the translator.

Even with phone services available, a slapdash approach to translation is the status quo. Providers and patients often rely on neighbors or children, who cannot legally act as interpreters in California.

I’m not saying culturally component care isn’t important. Although the term is broad, it leads to better outcomes through better communication and better patient compliance with therapy. But there is obviously a limit to what can be achieved in most of health care within reason and examples like the above show a naïveté amongst proponents of such care.

Then of course, there are examples of the opposite.

I train in a city where more than half the population speaks Spanish as a first language. Obviously that figure is likely even more impressive for the specific population served by the county hospital. The encatchment area of the hospital extends into territories where the prevalence of Spanish is even more complete. Many of these patients do not speak English in addition. And while translation services are often relatively easy to maintain the established process is haphazard and in more than one instance has failed.

This story has obviously been changed substantially but I think it is in line with some recent experiences which have frustrated me.

I had a patient recent who needed a neurosurgical procedure. He was an inpatient and it was my first time meeting him and his first time meeting a neurosurgeon; their was no established repoire or understanding about what we were about to discuss. He was a Spanish speaking only gentleman with no family. He had had extensive, destructive sinus surgery which had made him nearly unintelligible in speech at times. While the surgery wasn’t urgent, there was an opportunity it done the same day and move the patient’s care along. That obviously depended on, most importantly, discussing such with the patient.

So, after my halting introduction of myself in Spanish, knowing I was over my head I went to his nurse, who did not speak Spanish, and asked if he could help me find someone to translate. He rather unhelpfully, but not rudely, merely offered up a name of a tech who was on the floor who could translate. So I went to the front desk and inquired for the tech with the clerk, who not having seen him recently paged him overhead to the patient’s room. I went back and waited awkwardly with the patient. No one showed. Back to the clerk I went and inquired again. This time I asked for the charge nurse who the clerk promised to find and in the meantime she suggested I use the translation phone that exists on every ward and unit. While trying to explain that the patient’s speech was garbled, I still took the phone while I waited. I set up the phone and dialed in and the translator on the other end did his best but essentially could not comprehend the great majority of the patient’s responses. At the end of my discussion and introduction of what I thought we needed to do next for the patient, with surgery, he offered up questions which were useless and devolved into me trying to read his Spanish writing over the phone to the translator. The patient merely shook his head finally, shrugged and said, I think, in English, “Is okay.”

During the conversation over the translation phone the nurse popped in again and left, on a journey he said to find a translator. He didn’t return with any haste.

The entire ordeal took perhaps twenty or thirty minutes. No doubt the institution failed. I’m not sure, serving a majority Spanish speaking population, that organized, readily available, in person Spanish translation can even be called something like cultural competency under such circumstances. It seems even better practice than that; a necessity. And yet here we are.

To be fair I could’ve done better. A surgical intervention is a major life altering point and thirty minutes looking for the appropriate translator was worse than my patient deserved. I should called up the line of command in my pursuit. But in house, with sixty patients under care and consults stacking up in the emergency room, real time pressure exists. Not that I got, say, four consults while I was talking to the patient, only that there are other pressing things that require attention. A reason; not an excuse.

Wednesday, January 9th 2013

Do Nothing

I’ve been reminded recently how much of medicine is watch and wait. I’ve been reminded of it in the context of being on call and cross cover. When I’m not on service but I’m taking overnight call I think I probably do less fiddling and tampering with patient’s care than when I’m on service and seeing the same patients day in and day out. Getting along in training also probably predisposes me to such inactivity.

And I’m not sure that’s a bad thing.

As every resident, I get a lot of phone calls from nurses when I’m on call in house. A lot of it is tedious and just things to be taken care of from afar, such as the day team didn’t reorder restraints, and a lot of it is just unnecessary, such as the patient doesn’t have an incentive spirometer at the bedside at 2am, and a little bit of it deserves undivided attention and action, such as the patient has had a legitimate neurological status change, but some of it is just stuff that just raises a shrug. Examples from my last call include the fact that a patient’s urine output was only 20cc for an hour but their pressures were fine, that a lumbar lumbar drain hadn’t drained anything for the last hour but was tidaling, that a patient threw up once but already had prn antiemetics available, that a patient with a monitored head injury and concurrent ARDS and maxed ventilator settings on his current mode had a stable but less than ideal pCO2 of 44.

Thanks for the update, I guess, let’s just watch and see what happens over the next hour or two or three.

Behold the issues turn out not to be issues at all. The patient puts out plenty of urine over the next hour, the lumbar drain starts draining over the next two hours, the patient doesn’t vomit again, the patient’s pCO2 stays stable and he has no intracranial hypertension issues.

Maybe it is just a matter of better triage, teaching patience to those at the bedside. Then again, even if the phone call was after the still tidaling lumbar drain hadn’t drained anything in three hours my solution might still be to just stare at it. It seems to work. I guess helping the triage process and separating the wheat from the chaff and knowing when to just shrug and watch is just part of being a resident; maybe a physician in general.

Tuesday, January 8th 2013

Venous Sinus Thrombosis

In case you missed it our Secretary of State, Hilary Clinton, has a cerebral venous sinus thrombosis. Such may be a consequence of her mild traumatic brain injury earlier in December. But considering these can be relatively asymptomatic things, especially in older individuals, and that the madame Secretary has a likely procoaguable disposition, considering her history of deep venous thrombosis, it may just be this clot in her right transverse sinus was found incidentally on a follow up brain MRI.

The Heart has a good video on Mrs. Clinton’s condition. An NEJM review article from 2005 can be found here (PDF).

In general these are clots in the large draining veins from the brain. They’re associated with procoaguable states including a strong association with pregnancy; as well as with cancer and trauma and infections of the inner ear amongst other things but in at least 15% and perhaps as many as 30 or 40% of cases no underlying risk factor or etiology is identified. They can lead to raised intracranial pressure by cerebral edema in the areas where blood backs up and by affecting the reabsorption of cerebral spinal fluid. Raised intracranial pressure can have relatively non-specific findings including headache, nausea, the consequences of papilledema. At times they can lead to frank venous inarcts; venous strokes in the brain. These strokes can even be hemorrhagic. his can lead to more devastating consequences. Or they can be asymptomatic.

As with venous clots elsewhere the treatment is generally anticoagulants. And it appears Mrs. Clinton is back on coumadin, although there are other, newer oral anticoagulants that could serve the same treatment. Typically it would be expected for her to continue treatment for at least six months, depending on what repeat imaging and exam shows.

My thoughts are with her as she deals with this.

Monday, January 7th 2013

Foreign Medical Students In Texas

It is a medical education themed day as I return to blogging after a month off.

We’re potentially awaiting this month a ruling from the Texas Higher Education Coordinating Board on January 24th whether medical students at the for profit American University of the Caribbean can do clinical clerkships during their third and fourth years in Texas hospitals. This ruling following the Attorney’s General office giving an opinion that THECB does have the authority to grant or deny AUC’s request.

To be clear, this wouldn’t require hospitals to take these students but if the THECB rules in AUC’s favor it would allow the university to negotiate with hospitals in the state to allow their medical students to come through. Considering the money AUC is likely flash to secure spots for their students it is almost a forgone conclusion there will be a number of opportunities for their students in Texas.

I’ve written previously about growing opposition to foreign medical students rotating in the United States in states that already allow such. And there is much opposition amongst Texas medical schools and organized medicine and legislators.

Texas medical schools, charged with increasing enrollment to meet the state’s physician shortage, are already “starting to stumble over each other” finding their students the right clerkships, said Dr. Cynthia Jumper, who heads the Texas Medical Association’s medical education council and chairs the internal medicine department at Texas Tech University Health Sciences Center. While there may be a few extra positions available now, Jumper said, there won’t be for long. 
“What extra room there is now has already been spoken for,” she said.

Senate Higher Education Chairwoman Judith Zaffirini, D-Laredo, also voiced opposition. In a letter to Fred Heldenfels, the chairman of the coordinating board, she said approving AUC’s request would set a precedent opening the door to a slew of foreign schools, and she questioned the board’s authority to approve private professional programs. “May God bless you and inspire you to agree with my perspective,” she wrote.

It isn’t merely a matter of physical capacity, in the sense of how many medical students Texas hospitals can support. There is a limiting factor in that Texas medical students cannot, for all practical purposes, rotate on the same teams within hospital that AUC foreign medical students are on. Examples exist of citations from the Liaison Committee on Medical Education, the body that accredits all allopathic U.S. medical schools, for mixing of LCME and non-LCME medical students on clinical rotations. A summary of the accredidations standards of the LCME can be found here (PDF).

Personally, I hope to keep foreign medical students out of Texas hospitals. That may be a little bit of a surprising stance from me. I think, however, that the primary concern here should be in protecting the education of Texas’ own medical students, which the state already has significant investment in. I think foreign medical students taking up clinical clerkships in Texas hospitals may put that at risk.

Monday, January 7th 2013

Osteopathic and Allopathic Education in Texas

Osteopathy has an interesting history in the United States. Unlike other ‘opathies’ and rejections or alterations of allopathic medicine which arose in the eighteenth and nineteenth centuries, the history of Dr. Andrew Still’s treatment philosophy, is remarkable in the turn it took back towards biomedical principles and how leaders of osteopathic medicine in the twentieth century fought allopaths and the entrenched medical community to broaden their scope of practice until today when a D.O. degree is an equivalent of an M.D. degree anywhere in the United States.

I’ll ignore whatever debate remains over the benefits of osteopathy and manipulative medicine. Largely because the founding principles of osteopathy are largely nowhere to be found in the everday practices of doctors of osteopathic medicine. Very few D.O.s use manipulative medicine in their practices. And while there are some other distinctions between allopathic and osteopathic medical education in the United States, such continue to shrink. There has been a gradual infolding of osteopathy back into allopathic medicine; an irony of the fact osteopathic leaders at the beginning of this century worked so hard to be accepted by their counterparts in medicine. Nearly 70% of graduates, or perhaps more nowadays, of osteopathic medical schools do residencies sponsored by institutions focused on allopathic education.

No wonder there are irregular questions about the continued necessity of osteopathic medical education. From a 1993 article in the Journal of the American Osteopathic Association,

[T]hese changes…raise a number of disturbing questions for the profession. Foremost is the continued existence of or a need for osteopathic medicine in our society. Why should the United States support parallel medical systems on the assumption that osteopathic medicine is different when, after graduation, most DOs choose to train in the allopathic medical profession?

It’s a legitimate question, still being played out even twenty years after that article. On the one hand the number of osteopathic graduates, as all medical schools, continues to grow and new osteopathic medical schools continue to open. I’m not sure that hints at some unfilled need for osteopathy as it remains most of those graduates will largely shun such in their real world practice. And, on the other hand, slowly schools of osteopathic medicine are looking to award doctors of medicine in addition to, or as replacements of, their current doctor of osteopathic medicine degrees.

Such is the case at the school of osteopathic medicine in Texas. Several years in the works, and somewhat of a political nightmare to this point, the University of North Texas’ Health Science Center Texas College of Medicine is likely to have a bill introduced in the next legislative session to allow the school to offer an M.D. degree. So focused were some at the school on approval for an allopathic track that it created discord over a parallel move to merge the health science center with the University of North Texas at large.

Merger talk became a distraction, with questions raised about whether one effort hinged on the other or one would take precedence over the other.

When the merger issue came before the regents again in November, it was taken off the agenda. Jackson said it’s been tabled indefinitely.

Any change to the governing structure of the Fort Worth and Denton campuses would require approval from the Legislature, governor and Texas Higher Education Coordinating Board.

With the 2013 session starting Jan. 8, [UNT Chancellor] Jackson said

The president of the health science center seems to have voiced such a belief – that asking the legislature for the merger at the same time as asking them to approve the M.D. degree would be a distraction and reduce the chances of approval for the M.D. degree – in his contentious opposition to the merger. Such opposition eventually cost him his job last month.

Seeking permission for the M.D. degree I think heightens the question of purpose that continues to surround osteopathic medicine.

The D.O.s I know are largely excellent physicians. There is nothing in their education that distinguishes them. I also don’t personally know a single D.O. who has ever let it be known to me they routinely use something unique to osteopathy in their everyday practice. I’m not sure why then we continue to pay lip service to osteopathy and to distinguish ostoepaths and allopaths by the letters after their names. Maybe its time we were just all the same. Maybe if UNTHSC wants an M.D. degree for TCOM, then that should also be the end of its D.O. degree.