Monday, February 21, 2011

In Harm’s Way: Are There Consequences?

What if I decide that I want to go “in harms’ way”? It is my right as an American citizen, isn’t it? Then what if things go wrong and harm befalls me? Who picks up the pieces? Let’s look at some recent examples of folks who went in harm’s way.

On February 20th, two West Point Cadets decided to practice rappelling on Storm King Mountain. It was not part of their curriculum to rappel on a Sunday. The day was cold and very windy, possibly not the best day to climb a mountain. They became stranded on a rocky ledge and called for help via cell phone. Eight hours later after attempts to rescue them from the ground failed and in 50 mph winds and 20 degrees temperatures, a daring helicopter rescue was carried out by heroic NYPD cops. Thanks to luck and skill, no one was hurt.

Despite the common knowledge that pirates lurk near Somalia, some incredibly na├»ve [or incredibly stupid] people sailed their 58 foot yacht into dangerous waters off the coast of Oman last week and were captured. According to the New York Times, one of the party of four on the boat blogged before heading into the area, “I have NO [sic] idea what will happen in these ports, but perhaps we’ll do some local touring.” No doubt they will be seeing some very interesting sights.

In 2009, three American hikers wandered across the Iraqi border into Iran and were captured. One of the hikers, a woman was released on “humanitarian grounds” because she was sick. Also, $500,000 was posted as “bail.” The other two hikers, both males, are still being held. As lovely as Iraq seems from the pictures I’ve seen, it has to be right up there with Somalia as a place where I would not like to hike. But let’s compound the folly by straying into Iran.

What have we learned here?

People either don’t listen or feel that they are immune to the consequences of their actions. It is this same lack of accountability that permits people to smoke, drink alcohol to excess, not exercise, eat too much or use addictive drugs. Don’t worry, you will be cared for.

ADDENDUM [February 22, 2011]

Sadly, the four Americans on the yacht were killed. This tragedy did not have to happen. Details are a bit sketchy but four American warships and aerial drones are said to have been following the yacht. A spokesman for the pirates apparently had warned that the captives would be killed if any rescue attempts were made.

Friday, February 18, 2011

I categorically refuse to watch medical shows on television. Here's why.

Thanks to Karyn Traphagen who posted a link to the Grey’s Anatomy episode in which a surgeon tweeted while operating. Having just watched the 8 minute clip, my reservations about medical television shows are reinforced.[Updated on 1/31/13: I'm sorry to say the video has been taken down. Maybe it's available on Hulu.]

A surgeon is doing a Toupe procedure, an operation to prevent esophageal reflux, and [I guess] damages the colon and pancreas. A medical student is tweeting the progress of the surgery and taking questions from surgeons all over the country. The chief of surgery finds out about this because students who are ostensibly watching a case he is doing are following the tweeting case on their phones. During the surgery, the Twitter surgeon takes a break to have a milkshake and runs into the chief of surgery in the cafeteria. He tells her to stop tweeting during the procedure because he is worried about the medicolegal ramifications. She goes back to the OR and finds a leaking pseudoaneurysm of the splenic artery which necessitates a total pancreatectomy. She disobeys the order not to tweet and gets a number of helpful suggestions and insightful questions from the Twitterverse of surgeons. She realizes that removal of the entire pancreas will create a diabetes problem. To address that, she helicopters over to Tacoma Methodist to pick up the equipment to extract islet cells from the removed pancreas for injection into the portal vein. The chief of surgery receives a shout-out from a former resident via Twitter and is now converted to an avid Twitter supporter.

How the audience of Twitter surgeons found out that this case was ongoing was not stated.
I have never in my 40 years of surgery seen a surgeon take a milkshake break during a case.
Disobeying the chief of surgery’s orders is a good way to see what the job market is like.
In the world of fantasy which is television, there are surgeons at Mayo Clinic, Johns Hopkins and Emory who apparently have nothing else to do that day and are glued to their computers/smartphones breathlessly anticipating every twist and turn of the procedure.
Total pancreatectomy is rarely indicated even for gunshot wounds. She must have really screwed up the surgery to end up needing to do that.
It is not clear how the staff at Seattle Grace [the hospital of Grey’s Anatomy] is to be inserviced on islet cell extraction and transplantation.
Oh by the way, is there going to be a morbidity and mortality conference to discuss the colon and pancreas injuries during a simple procedure for esophageal reflux?

Other than those few issues, the episode was pretty realistic.

Monday, February 14, 2011

Statistics, Radiation and Childhood Cancers

A while ago, I tweeted that medical journalists should have a working knowledge of statistics. Perhaps that should be extended to those who perform peer review for journals as well. A report on Yahoo News via HealthDay [headlined “Greater Caution Urged for X-Rays in Pregnancy, Infants”] states “There's a small increased risk of cancer for children who had X-rays before they were 3 months old and those whose mothers had X-rays while pregnant, researchers say.”

A few paragraphs later comes this: “Children whose mothers had X-rays while pregnant had a slightly increased risk for all childhood cancers and for leukemia, though the increase was not statistically significant [emphasis added]. Children who had X-rays in early infancy had a small, non-significant [emphasis added] increased risk for all childhood cancers, leukemia and lymphoma.”

For those of you who still do not get it, an increased risk that is not statistically significant is the same as saying there is no difference in risk. A difference that is not statistically significant is simply not a difference at all. It could have happened by chance. It is misleading, if not downright dishonest, to state otherwise.

The paper actually does say that the risk for lymphoma only is statistically significantly increased but the odds ratio (odds ratio 5.14, 1.27 to 20.78) is quite wide due to the small numbers of patients in the study.

This was a case-control study of 2690 childhood cancer cases and 4858 age, sex, and region matched controls from the United Kingdom. It was published in the British Medical Journal on February 10, 2011.

There is heighten awareness in the literature about the risks of radiation from diagnostic tests. Real concern is warranted. But this report adds only noise and confusion.

Friday, February 11, 2011

New Diseases Discovered by Hospital Clerical Personnel

Here is a list of illnesses and terms found on actual patient admitting medical records at a hospital which shall remain nameless. The “illness” or term is followed by a translation when possible.

Fibial Fracture. There’s a tibia and a fibula but no fibia.

Subcutaneous hematuria. Hematoma (bruise) under the skin. Hematuria means blood in the urine.

Urinary constipation. Patient unable to pee.

Intelligent gait. ???

Bilateral sore throat. Last time I looked, the throat was not a paired structure.

Gullstones. What you would throw at a bird at the beach.

Umbilectomy. Umbilical hernia repair?

Protruded appendix. Perforated appendicitis.

Gastropsoriasis. Gastroparesis or slow emptying of the stomach.

Sphincter of Jedi. Sphincter of Oddi, a structure that controls the flow of bile into the duodenum.

Strangulated labia. I’m not going to touch that one.

More Proof That Our Country’s Education System is in Serious Trouble

A while back I posted a really difficult math problem from a 5th grade textbook. Like Fermat’s last theorem, it may take 350 years to be solved. Here is another one from that same book.

In case you can’t read it, it says, "Write a Problem: Write a two-step problem that contains a hidden question about buying something at the mall. Tell what the hidden question is and solve your problem. Use $8.95 somewhere in your equation. Write your answer in a complete sentence."

So far, all we have are the following:

A. If a tree falls in the forest does it still cost 8.95?
B. What is a hidden question? Where do you hide it?
C. What can you buy at the mall for $8.95?
D. I was looking for something I needed at Sharper Image. I only had $8.95. They threw me out. Hidden question: what could I possibly need that is sold at Sharper Image?

Wednesday, February 9, 2011

Hospital and Doctor Ratings: Junk Science? No, No Science at All

Pop statistician/philosopher Malcolm Gladwell takes down the ridiculous college rating process in this week’s New Yorker magazine. While pointing out the many problems with the way U.S. News goes about rankings colleges, he mentions a 2010 study published in Archives of Internal Medicine that similarly debunks the rankings of hospitals. That study found that reputation alone is the key to a hospital receiving a high ranking and the ranking has nothing to do with quality. This is true of the college ranking system too. A key point regarding the power of reputation is that as the rankings are publicized every year, the top hospitals and colleges become even more prestigious, which of course, enhances their reputations further.

The college ranking methodology takes into account a number of factors and weighs them in an arbitrary way. Gladwell feels that cost is not given enough emphasis as expensive private universities dominate the top of the list. When it comes to hospital rankings, U.S. News surveys only 250 physicians in each specialty and asks them to name the five best hospitals in their field. It is impossible for a hospital without an established national reputation to ever be ranked highly.

This whole charade is carried to an almost comical extreme by the folks at Castle Connolly, who bring you “America’s Top Doctors” and regional offshoots of the same concept. These ratings are eagerly awaited ever year and are the subject of lengthy articles in magazines. Advertising revenue is generated as hospitals tout their MDs who have been fortunate enough to have made the Castle Connolly list.

Here is a little secret. Castle Connolly sends questionnaires to hospital department chairs and asks them to name the best doctors in not only their fields but every medical specialty. No other criteria are used. Having been a department chairman for over 23 years, I can tell you that it is impossible for me to know anything about the quality of the work of any physician at another hospital or even sometimes another specialty in my own hospital. The vote is strictly by reputation. Many fine doctors make the list because reputations are very often correct. But not always. A surgeon can be well-known for research or involvement in organizations, but she may not necessarily be the best clinician around.

So what is a prospective patient to do? I’ve already blogged about the shortcomings of Healthgrades [here and here] and the CMS [Medicare] Physician Compare website is not ready for prime time. For now, I suggest you ask friends who may have had illnesses similar to yours for recommendations. Or you’ll have to trust the doctor who refers you to a specialist and your instincts when you meet her.

Thursday, February 3, 2011

Charting Requirements Interfere with Patient Care

Yesterday’s column on the burden of nurse documentation in the New York Times by Theresa Brown, RN was spot on. She details many of the rather onerous charting requirements mandated by myriad regulatory agencies and insurance companies. She laments the fact that the documentation is so time consuming that it takes away from her mission to care for the patient. She says that nursing has always been guided by the dictum “If it isn’t charted, it isn’t done,” and points out that charting everything a nurse does during a shift is impossible in reality.

The problem has been compounded by the electronic medical record which makes it easy to insert pop-ups and drop-downs so that anything some bureaucrat fancies can be added to the chart. Of course, the nurse still has to login and get past a number of screens before she finally reaches the section she wants. Here’s the bad news. Other than the bureaucrats and operatives from the Quality Assurance Improvement department, NO ONE READS THIS USELESS INFORMATION. It simply clutters up an already very “busy” electronic chart.

Like nurses, we physicians have similar, sometimes comical, charting responsibilities. For instance, the Surgical Care Improvement Project [SCIP]* has a relatively new rule that Foley catheters must be removed within two days after surgery to prevent infection. If the catheter is not removed, a progress note must be written documenting the reason the catheter was left in place. Recently, I was cited by “Thought Police” [Quality Assurance Improvement] spies because I failed to document why a catheter was still in place on the third post-op day. Never mind that the patient was on mechanical ventilation in irreversible septic shock, on vasoactive drugs with marginal urine output and died the next day. [As a side note, on researching this topic just now, I found that perioperative death is an “exclusion” regarding this measure. In other words, I should not have received a ding. I have forwarded the link to KGB HQ.**]

For years, we were told that Medicare wouldn’t pay the hospital if the medical coders listed anemia as a discharge diagnosis unless we wrote somewhere in a progress note that the anemia was due to blood loss after surgery. This was required even if it was patently obvious that the patient had undergone an operation and had lost blood.

I could go on, but I will spare you. A future blog will elaborate on the pros and cons of the electronic medical record.

*I have commented on the questionable value of SCIP here and here.

**Update. SCIP defines "perioperative" as the time between the end of the operation and discharge from the recovery room. Therefore, the citation stands. Of course, by that definition of perioperative, anyone patient dies in the recovery room would almost invariably be withing the first two postop days. So why bother to even mention it? Who knows?

Wednesday, February 2, 2011

Abdominopelvic CT Increases Diagnostic Certainty

A report from the Massachusetts General Hospital shows that abdominopelvic CT scans significantly increased diagnostic accuracy and changed patient management in a series of 584 prospectively studied non-trauma patients with abdominal pain. The paper was published ahead of print in the American Journal of Radiology.

Emergency physicians recorded their presumptive diagnoses after examining patients and before the CT scan was performed. Key findings were that CT scanning increased diagnostic certainty from 70% to 90% and resulted in changes in patient treatment plans in 42%. In addition, 25% of patients initially diagnosed with a problem thought to require surgery were discharged from the emergency department without further treatment.

The most common problems encountered were ureteral stones, bowel obstruction and no acute condition, which was thought to be the diagnosis in 77 patients before CT scanning. Post-CT scan, the number of patients with no acute condition was 174, representing a 126% increase in that finding.

The paper did not address cost or radiation exposure. Asked about radiation exposure, lead author Hani H. Abujudeh, M.D. said in an email, radiation to the patient can be decreased “…using the latest technologies [and] knowledge we have.”

A surgeon, who asked to remain anonymous, reviewed the paper and offered a different interpretation of the data. He said that based on the nearly 50% post-CT rate of change in the diagnoses of appendicitis and bowel obstruction, one could simply say that the emergency department physicians at MGH are not particularly astute diagnosticians. He went on to say that the use of CT scans for abdominal pain is so common at his hospital, “if you complain of abdominal pain to the [emergency department] triage nurse, you are given your [oral] contrast to drink while you are still in the waiting room!”

This paper will no doubt be cited as justification for the increasing use of CT scanning in the diagnosis of abdominal pain. The blogger Skeptical Scalpel has commented that the quest for diagnostic accuracy trumps concerns about radiation.