Archive for the ‘Medicine’ Category

If you’re a parent who is still on the fence, trying to decide whether or not to vaccinate your children, I’m going to try to be kind and helpful. Here is a link to a video by a physician and father, Dr. Zubin Damania, with facts that may address some of your fears.

If you’re firmly pro-disease and anti-vaccine, however, I am baffled at your irrationality and frankly enraged by it. I am speaking from the intensely personal point of view of a physician and mother who knows what it’s like to attend the funeral and watch the coffin of her own child being lowered into the ground.

My daughter Alexandra is dead. There is no vaccine that could have saved her. The only thing that could make that enduring grief any worse would be the knowledge that there was a vaccine, and she didn’t get it because of me.

The only bright side to the recent outbreak of measles in the northwestern U.S. is the fact that some parents are finally deciding to protect their children with vaccination, as the New York Times reported on February 16.

I’m old enough to remember the terror that my parents went through every summer as polio epidemics swept the country, and the miracle of standing in line to take the sugar cube with the first oral vaccine in 1961. I have two dear friends who are paraplegic as the result of childhood polio, and you don’t want to have the anti-vaccine conversation with them, I promise you.

Our duty — all of us, as human beings in a civilized society — is to make sure that we and our children are immune to measles, chickenpox, whooping cough, and other infectious diseases so we can protect those who can’t be vaccinated due to real medical problems. We are the herd that has to take responsibility for herd immunity.

Every single one of us has a duty to the cause of public health to be vaccinated ourselves, and a duty to our children to make sure that they are vaccinated on schedule. Yes, I understand that in rare cases the flu vaccine can result in Guillain-Barre syndrome, but I still get the shot every year. It’s my duty to protect my patients, my husband, my children, and my grandchildren from being exposed to the flu, which could happen in the early stage before I might even realize that I was getting sick.

It’s particularly mind-bending to see that some parents think diseases like measles and chickenpox are benign. For every 1000 children who catch measles, one to three will develop encephalitis. Of those, 10 to 15 percent will die, and many more will have permanent neurologic damage. Chickenpox too can lead to encephalitis, and the blisters can get infected and cause full-blown sepsis or pneumonia.

The death of Olivia Dahl

Have you read any of Roald Dahl’s books to your children, and watched Charlie and the Chocolate Factory or James and the Giant Peach with them? Did you know that his seven-year-old daughter Olivia died of measles encephalitis in 1962, before the MMR vaccine was available? Here is what Mr. Dahl wrote:

As the illness took its usual course, I can remember reading to her often in bed and not feeling particularly alarmed about it. Then one morning, when she was well on the road to recovery, I was sitting on her bed showing her how to fashion little animals out of colored pipe-cleaners, and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn’t do anything.

Are you feeling all right?’ I asked her.

‘I feel all sleepy’, she said.

In an hour, she was unconscious. In twelve hours, she was dead.”

For the rest of his life, Mr. Dahl pleaded with parents to vaccinate their children. Even today, there is little that can be done to save a child who develops measles encephalitis. What we can do is prevent it by vaccinating.

I would never wish for any parent, no matter how irresponsible and irrational the pro-disease advocates are, to suffer the relentless and indescribable grief of their child’s death. In centuries past, parents frequently lost more than one child, but the fact that children’s deaths were common didn’t lessen the pain. If you don’t believe me, read this:

There’s a narrow ridge in the graveyard
Would scarce stay a child in his race,
But to me and my thought it is wider
Than the s
tar-sown vague of Space.

Your logic, my friend, is perfect,
Your moral most drearily true;
But, since the earth clashed on her coffin,
I keep he
aring that, and not you.

Console if you will, I can bear it;
’T is a well-meant alms of breath;
But not all the preaching since Adam
Has made Death other than Death.

It is pagan; but wait till you feel it,—
That jar of our earth, that dull shock
When the ploughshare of deeper passion
Tears down to our primitive rock.

Communion in spirit! Forgive me,
But I, who am earthly and weak,
Would give all my incomes from dream-land
For a touch of her hand on my cheek.

That little shoe in the corner,
So worn and wrinkled and brown,
With its emptiness confutes you,
And argues your wisdom down.

That poem, “After the Burial“, was written by American poet James Russell Lowell, who suffered the loss of three of his four children in the mid-nineteenth century. He hit the mark. So did Ben Jonson, writing about the death of his first daughter in 1593.

I will never write as eloquently as they have. So here’s the bottom line. Get a grip. Vaccinate your kids.

For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.

But today, eight years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine:  burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.

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“I’m your friend,” Harvard Business School Professor Michael Porter, MBA, PhD, told a sometimes skeptical audience during his keynote address at the ASA’s annual meeting, ANESTHESIOLOGY 2016. “I’m trying to help you see a better way forward, and avoid the bad outcomes that may happen if we don’t transform healthcare.”

Porter is a well-known economist, an expert on business strategy, and the author of the book Redefining Health Care: Creating Value-Based Competition on Results. In his speech to the ASA, he argued the case for redefining health care by making “value for the patient” the unifying purpose, and he urged anesthesiologists to forget pay for volume.

“How should anesthesiologists engage in bundled payments?” Porter asked. “Jump on them!”

Explaining that he has spent the past 15 years immersed in studying health care delivery, Porter said that he looks on health care as one of the world’s “most fundamental and intractable problems.” He asked listeners to think again about anesthesiology practice, and its role and responsibilities in the future of health care.

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The best way to avoid being sued for malpractice is to make certain that all your patients are happy and all their outcomes are good.

Reality is seldom so rosy. Patients aren’t necessarily happy even when their clinical outcomes are as good as they can get. In the event of an undesired outcome, an unhappy patient may easily become a litigious one. A 2011 study in the New England Journal of Medicine estimated that 36 percent of physicians in low-risk specialties such as pediatrics, and 88 percent of physicians in high-risk surgical specialties, would face a malpractice claim by the age of 45. Those percentages climb to 75 percent of physicians in low-risk specialties and 99 percent of physicians in high-risk specialties by the age of 65.

Flaws in clinical practice guidelines

Can clinical practice guidelines protect us? We are all beset by the proliferating standards and guidelines of evidence-based medicine. It’s comforting to think that a court may consider adherence to a legitimate clinical practice guideline (CPG) as evidence of reasonable prudence and acceptable practice. At the same time, physicians know that guidelines are imperfect. Many guidelines are debated and revised over time, some are discontinued when they are found to do more harm than good, and some have been found to be contaminated by conflicts of interest.

Some examples:

>  How long should dual anti-platelet therapy be continued after drug-eluting stent placement? Guidelines currently advise dual antiplatelet therapy for six months to a year after stent placement, and aspirin for life. More recently, the Dual Antiplatelet Therapy (DAPT) study suggests that some patients may benefit from extending dual antiplatelet therapy beyond one year in terms of protection against myocardial infarction, but this benefit is accompanied by increased bleeding risk and a possible increase in all-cause mortality. Physicians are advised to “balance risk factors”.

>  Starting in 2001, there was a push toward much tighter control of blood glucose levels in ICU patients. Tight glucose control after cardiac surgery became a quality measure tracked by the Surgical Care Improvement Project (SCIP) and the Joint Commission. The only evidence basis for tight control was a single-center study that associated intensive insulin therapy with improved outcomes including fewer infections, less ventilator time, and a lower incidence of acute renal failure. But the results couldn’t be replicated. In a landmark multicenter report published in 2009, patients receiving intensive insulin therapy with glucose levels kept between 81 and 108 were shown to have more hypoglycemia, higher mortality, and no difference in morbidity or length of stay. Intensive insulin therapy promptly fell out of favor.

>  Many hospitals in the last several years abruptly switched from povidone-iodine antiseptic solution to chlorhexidine-alcohol (ChloraPrep®) for skin preparation before surgery. They did so on the basis of a 2010 study that claimed substantial benefit for ChloraPrep in reducing the risk of surgical site infection (SSI). But in 2014 CareFusion Corp., the manufacturer of ChloraPrep, agreed to pay the government $40 million to resolve Department of Justice (DOJ) allegations that the company paid kickbacks to boost sales of ChloraPrep, and promoted it for uses that aren’t FDA-approved. The DOJ complaint said the company paid $11.6 million in kickbacks to Dr. Charles Denham, who served at the time as co-chair of the Safe Practices Committee at the National Quality Forum and the chair of Leapfrog’s Safe Practices Committee. He championed the use of ChloraPrep without disclosing his relationship with CareFusion. Subsequent studies have not demonstrated the superiority of any commonly used skin preparation agent in reducing the risk of SSI.

Though the evidence may be flawed, evidence-based medicine has shown an alarming tendency to evolve from guidelines into inflexible rules, especially if payment is linked to them. Physicians may come under pressure from regulators and hospital administrators to apply these rules mechanically, with inadequate attention to context or to a patient’s other health issues. As an excellent article in the British Medical Journal last year pointed out dryly, “The patient with a single condition that maps unproblematically to a single evidence-based guideline is becoming a rarity.” A guideline for the management of one risk factor or disease “may cause or exacerbate another—most commonly through the perils of polypharmacy in the older patient.”

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“I’m here to say ‘Yes, they can,’ which is different from ‘Yes, they always do,’” says James Moore, MD, President-Elect of the California Society of Anesthesiologists (CSA).

To the contrary, enthusiasm for electronic medical records (EHRs) is part of a “syndrome of inappropriate overconfidence in computing,” argues Christine Doyle, MD, the CSA’s Speaker of the House.

The two physician anesthesiologists (and self-identified “computer geeks”) squared off in a point-counterpoint debate in New Orleans as part of the American Society of Anesthesiologists (ASA) annual meeting, with Dr. Moore defending the benefits of EHRs and Dr. Doyle arguing against them. Dr. Doyle chairs the ASA’s Committee on Electronic Media and Information Technology, while Dr. Moore leads the implementation of the anesthesia information management system (AIMS) at UCLA.

Legibility, accuracy, quality

Dr. Moore defined safety in anesthesia care as “minimizing patient injury resulting from or occurring during anesthesia, and keeping surgeons from harming patients any more than they have to.” He said that computerization contributes to safe anesthesia care by improving legibility, offering clinical decision support with readily available reference information, and providing alerts and reminders.

Computer tracking of the anesthetized patient’s vital signs is more accurate, Dr. Moore said. It prevents the “normalization” of blood pressure that tends to appear on the paper record. Quality reports are easier to generate and outcomes are easier to measure with EHRs in place, he noted. “Postop troponin levels and acute kidney injury are easy to track.”

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