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Archive for May, 2013

Monday, May 27th 2013

Playing A Guitar During Brain Surgery

It is common practice in some techniques for putting in deep brain stimulator electrodes to keep patient’s awake to make sure the electrode is in the right place and giving good symptom relief. Likewise for parts of some surgeries for brain tumors you might have a patient awake to “map” their brain surrounding the tumor so as to not damage important parts that control things like movements or speech. You may ask patients to do certain tasks while they’re awake so that you can see if the stimulation is working or see if an area of the brain is involved in such a task. I don’t think I’ve ever heard of anyone playing the guitar during a surgery however.

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Monday, May 27th 2013

Does It Matter Where You Die?

Injury to the brain continues to be a unique thing in medicine. These injuries are scary and unfamiliar to many health care providers. There is a finality to them. Their consequences are hidden a little bit; the asystole is easy to figure in the emergency room but the suppression and brain death isn’t something so easily recognized.

They’re what you might imagine, along with polytrauma, as poster child conditions for tertiarization and transfer to a higher level of care.

In truly catastrophic injury to the brain however, I’m not sure that’s a good thing.

My institution has had a small discussion lately on just what ethics and the law requires of us as a place with full neuro specialty coverage.

I’ll make up an example:

A 61 year old man comes into a small community hospital’s emergency room. He was found down at home by his wife and last seen normal four hours previously. He wouldn’t wake up and he was breathing slowly and shallowly. The ambulance crew intubated him. In the emergency room his pupils are large and don’t react to light and he doesn’t do anything when the doctor hurts him. He’s in a very deep coma. If the physician working the emergency room felt comfortable doing a brain death exam, which he doesn’t, the patient might have some very primitive reflexes left but his condition is very serious.

A CT scan of the head is performed and shows a large bleed within the brain.

The bleed was probably caused by high blood pressure. In reality however, the patient’s condition is essentially terminal and the cause of the bleed isn’t important at this point.

The small hospital has an intensive care unit and an open bed. It however has no neurosurgeons, nor indeed even neurologists who round at the hospital. And so the physician in the emergency room starts trying to transfer the patient to a hospital where a neurosurgeon can see the patient.

There are really two issues here. The first is a legal issue concerning a law called EMTALA. EMTALA is a law that dictates transfers for higher care amongst hospitals that accept Medicare (virtually all hospitals). In very broad terms it puts responsibilities and requirements on both the hospital trying to transfer the patient and the hospital that might accept the patient. The former has a responsibility to stabilize a patient. They cannot refuse care in an emergency as a matter of lack of payment or inquire about payment prior to treatment to stabilize. Nor can they transfer a patient after stabilization merely as a matter of lack of ability to pay. The latter has a non-discrimination requirement, that specifically reads,

A participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers as identified by the secretary in regulation) shall
not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual.

Case law on the non-discrimination provision is scarce but in catastrophic injury, where no specialized intervention will alter the course of the patient’s condition, I would argue that the patient doesn’t require specialized care. And not merely cases where the patient is brain dead at the time of the transfer request but also in situations where brain death is inevitable or the condition is otherwise not survivable. The patient and family can proceed to comfort measures at any hospital, there is no specialization about such care.

The second issue is an ethical one. Do hospitals with specialized capabilities owe something to patients and families to transfer as a matter of finality and closure. In that we’re saying, “Watch, we did everything we could…”?

While I’m somewhat empathetic to such an argument I have trouble with it. I think it reflects a problem in both the expectations we have of health care as patients and how physicians are trained to deal with end of life. Really it is a shame for physicians to come out of training without basic palliative and communication skills. Even the physician in the small rural emergency room should have such a skill set. The capability to have an end of life discussion with families, even if the medical issue falls somewhat outside their scope of specialty.

I’m also somewhat disappointed in how some referring physicians appear to place priority in getting the patient off their hands over the patient’s well being. I’ve had cases where even after discussion with the consulting physician at an outside hospital and having seen the films and described in no uncertain terms to the other doc that the injury is not survivable that they continue to press for transfer.

I may be wearing blinders here but, and I think much of this is subconscious, I can only draw a single conclusion from such arguing. The continued pressure to accept the patient in transfer, after I’ve explained there is nothing to do for them, is a condemnation of my analysis of the situation. They’re basically calling into question my competency; my faculty’s compentency.

And I’m okay with that in the sense that I’m not going to take offense. What I have trouble with is they’re now trying to transfer their patient to a consultant who they don’t think is competent.

I don’t know how they can have the patient’s best interests in mind and work to transfer them to another physician they’ve basically said they don’t trust.

The issue gets more complex of course and I could continue writing. What if the patient was 6 months old instead of 61 years but the situation, in terms of the finality of the condition, remained the same? How many physicians on the line at the accepting hospital are literally too lazy to accept the transfer and work for any reason not to?

In general however, in an honest physician-to-physician phone call, with terminal conditions, where nothing will be done at the accepting hospital, no matter the patient’s age, I’m not sure transfer is a good thing. It significantly contributes to costs, provides false hope and contributes to our societal expectations at the end of life.

Saturday, May 25th 2013

Maryland Wants More Control Over What Hospitals Charge

Maryland is unique amongst states,

In other states, each time a hospital provides a service, it has to negotiate how much money it receives from an insurer. The time-consuming and often contentious process results in widely varying prices for the same procedures.

Hospitals pushed for the highest possible payouts partly because they say they do not receive enough from Medicare, the federal program that reimburses medical providers for their care of the elderly.

Maryland put an end to the wrangling. It established a state commission that directly set rates for procedures at all of its 46 hospitals. Over time, hospitals and insurers embraced the system because they knew exactly what to expect.

But, as expenses in health care grew rapidly, the program did a poor job keeping up for hospitals and creating an incentive for hospitals to admit as many patients as possible,

Part of the problem with the old system is that it gave hospitals an incentive to admit as many people as possible. The more patients who walked through the door, the more the hospitals would get paid.

So Maryland officials came up with a new approach. On top of setting rates for individual procedures, they are proposing a cap on the growth of the total amount the hospital system spends per person in the state. The plan also allows hospitals to charge higher prices if they adopt preventive-care methods that improve patient health and reduce repeat visits, said Maryland’s health secretary, Joshua Sharfstein.

Boy, can’t say I support this proposal.

Wednesday, May 22nd 2013

The Plate In The Head

Unfortunately sometimes in neurosurgery when you do a surgery you have to leave the part of the skull you remove to access the brain off. The most common situation is in neurotrauma.

A patient has had an extensive injury and perhaps there scalp has been opened and the underlying skull is exposed to the outside and poses a real infection risk.

Or their skull has been fractured so badly that it can’t cosmetically be put back together very well.

Or they have their skull put back on after surgery but it gets infected and then the infected piece of bone has to be removed and can’t be used again.

In these cases we sometimes use custom made implants which are built by biomedical firms off of a special CT scan. They are pretty amazing and can give great results. They’re also expensive and to be honest I’m not one hundred percent sure how they’re made.

But it comes as no surprise to me that the rise of commercial 3D printing might disrupt the, admittedly small, market for such cranioplasty implants and substantially lower costs.

Now replacing large portions of people’s skulls is not necessarily new. Back in 1997, Science Daily reported on advances in implants that involved using CT and MRI scans to create a model of the skull and then have a special implant manufactured from medical-grade plastic. What’s different about the 3D printed approach is that implants are lower cost and can be customized to specifically fit the patient. Additionally, if the implant doesn’t quite work out, replacements are readily available.

Other implants are coming, I would imagine. It is likely to be pretty impressive technology.

Monday, May 20th 2013

Financial Toxicity In Cancer Care

I wouldn’t know what to tell patients if they raised the issues of the cost of care. Let me correct that, I don’t know what to tell them. Questions like: “How much will this cost?” or “Are there any resources to help pay for this?” do come up in my patient encounters. I can do little more than shrug ignorantly and suggest a call to the social worker on the floor or in the clinic.

Now some limited research out of Duke looks at how discussions about cost in oncological care impact such,

The people who did talk about financial issues told the researchers it was helpful to do so. “They said it helped decrease their expenses,” Zafar says.

[...]

“I treat colon cancer, and I have the option of giving a drug as an IV or an oral pill,” he says. “If I give the pill form, the patient faces a copay even if they have insurance, and that copay goes away if I give the intravenous version.”

[...]

“We can’t necessarily give the best care to patients unless we address cost,” Zafar says.

Cost and the taboo about discussing such is obviously an obstacle to care. I wish I was better informed on resources for my patients. I’ve grown better over the course of my training but still feel pretty impotent in pointing them in the right direction.

Monday, May 20th 2013

Your Robotic Surgery Costs More, Doesn’t Get You More

Robotic surgery has been a marketing point for plenty of hospitals across the country. Topping the list is the da Vinci surgical system used primarily in urologic and gynecologic surgeries and some cardiac surgeries. But these systems are expensive, costing nearly 2 million dollars. And the benefits of such, as compared to traditional minimally invasive surgery, such as with laprascopy, is highly questionable.

The surgery is “minimally invasive,” and there is some small evidence, although hardly uniform, that they may be an easier thing to learn than laproscopy. For some procedures, notably prostatectomy, the robot offers the only “minimally invasive” option. But the growth in robotic surgery, and where manufacturer’s are marketing are in procedures with other, cheaper, minimally invasive alternatives.

There is hardly an obstetrician/gynecologist or urologist or general surgeon graduating training in the western world today without extensive laprascopy experience. Heck, after a single year of general surgery, which I’m now well removed from, I almost feel comfortable taking out a gallbladder with a scope. Not that that’s comparative in difficulty to a hysterectomy with a scope (which may be why there hasn’t been a splurge for using the robots from cholecystectomies…yet) but you get the idea. I’m not sure the increased costs associated with robotic surgery can be excused as allowing a subset of older surgeons to easily expand their limited minimally invasive repertoire.

The benefits of robotic surgery have simply not been born out in the literature. See here and here and here.

Robotically assisted and laparoscopic hysterectomy had similar morbidity profiles, but the use of robotic technology resulted in substantially more costs.

The growth in these procedures is being driven largely by marketing. Marketing to providers and directly to consumers. The technology is presented as ideal for “unique” cases. But such obviously is silly. As a patient, my future or your current “unique” case, has been well represented in the studies.

Given my particular health history and current diagnosis, and based on the reading I have done and my consultation with my oncologist, I believe that da Vinci is likely to bring some genuine benefits to my situation. Not only will the surgical incisions be small (minimally invasive), easing my recovery significantly, during the procedure, as this ABC News video shows, the robot’s dexterous mobility and 3D visualization will offer heightened precision. Dr. Irvin has called da Vinci “a quantum leap” forward in treating gynecological malignancies, and that sounds good to me.

Such does little more that contribute to America’s ridiculous health care spending.

I do see a final benefit to this wide adoption. There’s a very legitimate chance that this technology will evolve and improve into systems that truly have benefits. The da vinci may be a precursor to automation or something. Adoption and support obviously make further research and investment possible. But I’m not sure even that’s an adequate excuse for the wide adoption. Maybe skip picking whose going to do your mitral valve replacement based on a billboard for now.

Friday, May 17th 2013

Biological Calculators

Biological computers are not new. There is continual work on creating circuits from cells. Now work out of MIT on an analog computational system. Big enough for MIT to issue a press release.

To create an analog adding or multiplying circuit that can calculate the total quantity of two or more compounds in a cell, the researchers combined two circuits, each of which responds to a different input. In one circuit, a sugar called arabinose turns on a transcription factor that activates the gene that codes for green fluorescent protein (GFP). In the second, a signaling molecule known as AHL also turns on a gene that produces GFP. By measuring the total amount of GFP, the total amount of both inputs can be calculated.

To subtract or divide, the researchers swapped one of the activator transcription factors with a repressor, which turns off production of GFP when the input molecule is present. The team also built an analog square root circuit that requires just two parts, while a recently reported digital synthetic circuit for performing square roots had more than 100.

Worth a look just as a matter of curiosity.

Thursday, May 16th 2013

Your Next Prescription Will Come From A Computer

Vinod Khlosa has already made it clear Silicon Valley will be at the forefront of automating health care. He made waves last year by saying that 80% of what physicians do can be done as well or better by a computer.

I can’t fault the premise that diagnoses and interpretation of studies and prescription of therapies are soon to be carried out better by computers than physicians. Now making headlines is the famous IBM supercomputer Watson. The former Jeopardy champion is being trained at Sloan-Kettering and The Cleveland Clinic.

In Silicon Valley and other centers of innovation, investors and engineers talk casually about machines’ taking the place of doctors, serving as diagnosticians and even surgeons—doing the same work, with better results, for a lot less money. The idea, they say, is no more fanciful than the notion of self-driving cars, experimental versions of which are already cruising California streets.

Of course, it will be a generational shift to accept such automation without significant human interface. But such will come. Such is coming. As well, I feel pretty safe that my job as a surgeon as safe for a while longer.

Monday, May 6th 2013

Like All Insurance, Medicaid’s Role In Health Debated

Last week you could watch liberals scramble in response to a New England Journal of Medicine published study.

In 2008 Oregon found resources within the state budget to expand Medicaid. There were far more eligible for the expansion than funds available. Oregon held a lottery to enroll 10,000 new people onto the Medicaid rolls. Harvard, MIT and RAND have a group who saw that lottery as a great playground for studies. The first of these studies has now published its results. The study followed approximately 6,000 people who got Medicaid in 2008 and 6,000 who didn’t and looked at how their blood pressure, cholesterol, diabetes and depression did post randomization. Here’s the important quote from the conclusion that has so many talking,

This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years

As the Affordable Care Act promises the greatest increase in covering the uninsured by Medicaid expansion, if states take it, the study is important.

I linked to Mother Jones above. Here’s what Kevin Drum had to say,

It’s more likely that access to Medicaid did improve health outcomes than that it had zero or negative effects. It’s just that the study was too small to say that with certainty. For laymen, as opposed to stat geeks, the headline result of the Oregon study was “Possibly positive but inconclusive,” not “Had no effect.”

Here’s Jonathan Cohn at The New Republic,

Of course, even if Medicaid isn’t improving health, it’s certainly not making health worse, as some critics have claimed. Meanwhile, it’s improving mental health and providing economic security to some of the most economically vulnerable people in the country.

Justin Wolfers resorted to hypotheticals,


And, as a final example, here’s Matt Yglesias,


There are many nuances that need to be realized about the this study. The measures in the Oregon study where all surrogates for long term health. Admittedly hardly definitive quantities. And it “trended” towards significance in those measures. And we don’t know what the study’s power was.

I concede that significance is a relative crude tool in research. See here for a good explanation of such. But I think that fact plays poorly for this study. The reality is that asking to find a significance defined as a p <0.05, depending on pre-test probabilities, is not asking a lot.

Even without knowing the power with specificity, if this study couldn’t find signifigance at that level then to raise policy questions based on this study is not unreasonable. The beneficial effects of Medicaid on these quantities must be small if they’re real.

And so, only Kevin Drum in hindsight realized the real question this study raises,

Even if they’re real, are these results worth the money spent? That’s a different question, and there’s just no way to answer it with this study. That would require a much larger, longer-term research project.

I strongly disagree with the assertion this study doesn’t help answer that question.

The fact that most proponents of the Affordable Care Act are loathe to discuss, in my limited experience, is the fact that insurance status is not a terribly strong influencer of health. Sure, it influences health utilization and some surrogate markers. But I’m with the studies that imply its effect on major things like mortality is negligible conceding that such is debated.

The Institute of Medicine’s estimate that lack of insurance leads to 18,000 excess deaths each year is almost certainly incorrect. It is not possible to draw firm causal inferences from the results of observational analyses, but there is little evidence to suggest that extending insurance coverage to all adults would have a large effect on the number of deaths in the United States.

The link in the quote is my own.

There are two associations that stunningly are a matter of debate.

The first is the association between insurance status and health care access. Especially with the Medicaid population there are other impressive obstacles to utilizing health care. Those include education and understanding of health issues, time constraints, literacy rates, angst at interacting with providers of different socioeconomic status amongst others. No matter their insurance status those of lower socioeconomic status utilize less health care and have poorer health.

The second is even more stunning, the association between health care access and health. It is true access to care is sometimes associated with secondary measures of health – some of the same measures in the Oregon study and others – but its association with the big quantities such as life expectancy is hardly unequivocal.

I find that personally a little bit shocking.

No doubt health care saves lives and improves health. Our own anecdotes tell us that. But it may very well be doing that on the margins. On a population level how much it effects such, especially as compared to things we might label under the umbrella ‘public health’ is questionable. And so we’re expanding Medicaid at considerable costs and for, perhaps, limited benefit. To what such limited benefit this study may help elucidate. And that is certainly something worthy of policy debate.

The issue is complex. There are cost savings and cost shifting in expansion and there are benefits to consider other than large population based health measures. But to pretend that such doesn’t deserve debate and that this Oregon study doesn’t inform that debate is silly.

The Oregon study is a blow to the logic behind Medicaid expansion.

Sunday, May 5th 2013

Post Spinal Tap Headaches Can Be A Real Problem


You can imagine that if the pressure inside of your head is high you might, amongst other things, have a headache. Your skull is a closed box and the contents of the box are relatively fixed with a certain amount of blood, cerebrospinal fluid and brain. Adding additional contents to the box such as blood or cerebrospinal fluid, such as in hydrocephalus or pseudotumor cerebri, or more brain, such as in some tumors, increases the contents without increasing the volume which necessarily increases the pressure.

What’s interesting is that you can also get terrible headaches if the pressure is too low. Such appears to have happened to Chicago Bulls forward Luol Deng.

Your spinal cord, and the nerves that run to your legs, bowel and bladder, are protected by a tough sheath known as dura. The spinal cord and the nerves are bathed in a fluid your body makes, known as cerebrospinal fluid, which is contained within the dura as well. Some diseases require sampling the cerebrospinal fluid to help diagnose them. Examples of such include hydrocephalus, to see if the pressure is high, or meningitis or multiple sclerosis.

In Luol Deng’s case he apparently had symptoms that made the ER physicians concerned that he might have meningitis and so he had a lumbar puncture. This is a procedure wherein a needle is inserted into the back, between the vertebrae, and through the dura to get a sample of cerebrospinal fluid.

In most cases the hole the needle makes in the dura heals up easily by itself. However sometimes the durotomy does not heal and cerebrospinal fluid can continue to leak through the hole after the lumbar puncture is done.

The image above is technically post operative, involving a surgery where the dura had to be opened. However the idea is similar, you can see the cerebrospinal fluid (and actually the nerves themselves) are leaking out of the dura. Because the cerebrospinal fluid in your back is continuous with the cerebrospinal fluid in your head and around your brain, a persistent leakage of cerebrospinal fluid can actually lower the pressure inside your head. Low intracranial pressure can lead to headaches as well.

The initial treatment for cerebrospinal fluid leaks from small holes in the dura, such as typically caused with a lumbar puncture, is to have the patient lay flat for several days. The idea is that cerebrospinal fluid is more likely to leak when you’re upright and gravity is pulling the fluid down towards the hole. If you’re flat and prevent a continuous leak the dura can heal itself. If that fails then often a blood patch will be attempted. Here blood is drawn from a patient’s vein and then injected into the area right around the durotomy to try to produce a clot that seals the leak. Failing that, and incredibly rarely, patients may have to go to the operating room to have surgery to close the leak.

It sounds as if Luol Deng may be feeling better. I wish him the best. As I write this his teammates are winning Game 7 of their second round matchup with the Brooklyn Nets.