Friday, February 22, 2019

Doctors share amusing comments seen in patient charts


"Doctors share amusing comments seen in patient charts" is a new post of mine on Physician's Weekly. Here is the link

Monday, February 4, 2019

An unusual end-of-life case


I just posted a new article on Physician's Weekly.

An end-of-life case with a different twist. It's very easy for things to go wrong.

Here's the link.

Thursday, January 24, 2019

A letter to my loyal readers

Dear readers,

You may have noticed my blog posts have decreased in number over the last year or two. A couple of factors have brought about this change.

After blogging for more than eight years, I am running out of ideas. When I started, I had accumulated a number of things I wanted to say about medicine, surgery, medical education, research, and other topics.

The second issue is the Blogger platform I use is very clunky and slow. I’m sure it has discouraged people from commenting. It even runs slow for me. I just can’t face the hassle of migrating the blog to another site like WordPress.

I am going to try to blog exclusively for Physician’s Weekly, a website I have written for regularly over the last six or so years.

Yesterday, I posted “Odd medical stories. The third one is jaw-dropping” on the PW site. Here is the link.

Whenever the next post is ready, I will link to it from here so those of you who are on my email list will know a new piece is available. I hope the extra click is not too inconvenient for you.

Of course, I will continue to promote my blog on Twitter. If you have not followed me there, you can by finding my twitter handle, @SkepticScalpel.

I thank you for reading and hope you will continue to do so.

Sincerely yours,

Skeptical Scalpel

Thursday, January 10, 2019

Should residency program directors look at applicants’ social media activity?

Please take a look at my new post on Physician's Weekly: My thoughts on whether residency program directors should review applicants' social media activity.

Friday, January 4, 2019

For longevity, is it better to be short or tall?

Being short is associated with worse outcomes for critically ill adults.

A large retrospective study of 233,000 men and 184,000 women consecutively admitted to 210 ICUs in the UK over a six-year period found hospital and ICU mortality decreased with increasing height after adjusting for available potential confounders. The difference was statistically significant.

The definition of short or tall was based on the median height of the subjects—175 cm (5’9”) for men and 162 cm (5’2”) for women. These figures are nearly the same as the averages for non-hospitalized adults.

The study had several limitations. Height was measured in just 44.5% of the group while the rest were based on estimates. However, the authors noted the median estimated height was exactly the same as the measured height for men and only 1 cm different for women, and measuring height in critically ill patients is difficult.

Friday, December 7, 2018

A fatal medication error

A 75-year-old woman died at Vanderbilt University Medical Center after receiving intravenous vecuronium, a drug that causes muscle paralysis, instead of Versed, a sedative.

Here’s what happened.

She had been recovering well from an intraparenchymal brain hematoma after a fall. While awaiting a full body positron emission tomography (PET) scan in the radiology department, the patient said she was anxious about being in the machine because she was claustrophobic.

A doctor ordered Versed 2 mg IV in the electronic medical record at 2:47 PM. Two minutes later, the pharmacy verified the order. The radiology department staff said they could not give the medication because they were very busy and the patient would need to be monitored.

So nurse A, who was functioning as the “help all” nurse was asked by the patient’s nurse, nurse B, to go to radiology and give the medication. At 2:59 PM, nurse A went to the automated dispensing cabinet (ADC) and searched for Versed in the patient’s profile. When she couldn’t find the drug listed, she selected the “override” setting to search for the drug. She entered the first two letters of the drug, VE, and clicked on the first medication that popped up.

Wednesday, November 28, 2018

Can you be held liable for resuscitating a patient who has a DNR order?

A New Mexico woman, suffering from Dercum’s disease (adiposis dolorosa) which causes painful fatty tumors, is suing a Santa Fe hospital and an emergency physician claiming she was the victim of two negligent acts in 2016.

One, according to the Albuquerque Journal, she told hospital personnel she was allergic to Dilaudid but went into cardiac arrest after receiving an injection of the drug.

Two, despite the presence of a lawfully executed “do not resuscitate” (DNR) advance directive, she was successfully resuscitated and now faces continued pain and medical bills.

The staff had been aware of her DNR order and had even issued her a purple bracelet labeled “DNR.” However since the cardiac arrest was allegedly caused by an allergic reaction to Dilaudid, the staff may have felt her problem was not related to her illness and would likely result in a successful resuscitation.

While researching this subject, I found several instances of patients or families suing hospitals and doctors for failing to heed a DNR order or what some have called “wrongful life.”

However, I found only one major case that had gone to conclusion. A Georgia woman had both an advance directive and a healthcare proxy—her granddaughter. She was admitted to a hospital for a cough and eventually required a thoracentesis. The healthcare proxy agreed to allow the procedure to be done but specifically said her grandmother did not want intubation or mechanical ventilation.

A 2017 paper in The Journal of Clinical Ethics said the patient was temporarily intubated and ventilated during the thoracentesis. She was extubated, but a bout of respiratory distress was treated with intubation and mechanical ventilation again without consulting the granddaughter. The patient died two weeks later.

The granddaughter sued, and the hospital settled for $1,000,000. I believe this is the first such case settled for that much money. The biggest problem was failure of the doctor to communicate with the healthcare proxy.

Many issues in medicine are not black or white. Here’s the other side of the story. An elderly Boston man suffered a cardiac arrest in a hospital CT scanner and was resuscitated. The resident who treated him wrote that during the code, a nurse discovered a 6-year-old advance directive saying he did not want to be resuscitated in his chart.

But the code team noted he had walked into the hospital for the test and felt certain they could save him. They contacted his son and healthcare proxy who said “My father would want everything done to save his life.” The code was successful. He was weaned from mechanical ventilation and extubated after a few hours. He thanked his doctor and was discharged from the hospital two days later.

Some take-home points:

A DNR order and an advance directive may not necessarily be the same. For more information, read an interview with the plaintiff’s lawyer in the Georgia case.

Whether to resuscitate a patient or not may depend on the circumstances [e.g., whether an event is likely reversible or not], the wording of an advance directive, and/or the wishes of the healthcare proxy.

If possible, explain the possible scenarios and outcomes of resuscitation and DNR to your patients and their families well before a cardiac arrest occurs.

Communicate with patients and their healthcare proxies.