July 27th, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips
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The following is a message that I received from a reader:
“Professor Auerbach – I am an avid reader of your blog ‘Medicine for the Outdoors.’ Your two posts about foot blisters are really interesting. In my hiking experience there is another foot related issue, that is the subungual hematoma in the toenail. I think it could be an interesting subject in one of your blog posts. Thank you very much for the attention.”
Well, it just so happens that I have been a sufferer myself, so I’m happy to write a bit about this. Subungual hematoma refers to blood under a toenail or fingernail. In the fingers, this usually occurs from a blow or pinch, such as catching a finger in a door or striking it with a hammer. In the foot, it is commonly caused by repetitive blows in a confined space, such as hiking in a boot with a toe-box that is too small and/or too stiff. The photo above is my foot after a 10 mile hike over rocky terrain in hiking shoes that didn’t fit quite right. They were broken in, but they weren’t sufficiently flexible for that type of hike. A couple of hours in, I knew I was in trouble because of the pain, but there was no turning back. No surprise, when I took off my sock, I saw the blue color and knew that eventually that particular toenail was a goner.
What can be done about this condition? When it first happens, applying an ice pack might relieve the pain. Certainly, you should trade out the poorly fitted shoes for ones that provide greater room and comfort. If possible, curtail hiking activities for a day or two, and let the situation settle, or the blood collection might increase.
When a fingertip is smashed between two objects, there is frequently a rapid blue discoloration of the fingernail, which is caused by a collection of blood underneath the nail. Pain from the pressure may be quite severe. If the pain is intolerable, it is necessary to create a small hole in the nail directly over the collection of blood, to allow the blood to drain and thus relieve the pressure. This can be done during the first 24 to 48 hours following the injury by heating a paper clip or similar-diameter metal wire to red-hot temperature in a flame (taking care not to burn your fingers while holding the other end of the wire; use a needle-nose pliers, if available) and quickly pressing it through the nail. Another technique is to drill a small hole in the nail by twirling a scalpel blade, sharp knife, or needle. As soon as the nail is penetrated, blood will spurt out, and the pain will be considerably lessened. Before and after the procedure, the finger should be washed carefully. If the procedure was not performed under sterile conditions, administer an antibiotic (such as dicloxacillin, erythromycin or cephalexin) for 3 days.
In the case of my toe (above), the pain subsided with a day’s rest from hiking, so there was no benefit to be obtained by draining the blood. A new nail grew in underneath the one shown in the picture, with the entire process taking a full nine months from injury to nail replacement.
This post, Blood Under The Nail – What To Do, was originally published on
Healthine.com by Paul Auerbach, M.D..
July 27th, 2009 by Nicholas Genes, M.D., Ph.D. in Better Health Network, News, Opinion
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Friends visiting New York City this summer keep asking if it’s safe. As in, will they be catching and suffering from novel H1N1 (swine) flu.
I like to think my friends are pretty sharp, discerning folks (after all, they’re choosing my company) so I have to attribute these inappropriate questions to a wider problem.
For reference, here’s the latest and thought probably not last NYC DOH guideline on H1N1, which notes about 900 hospitalization and 45 deaths in H1N1+ patients over three months. About three quarters of these patients had at least one risk factor such as existing lung disease.
This deaths and hospitalizations are concerning, naturally, but some perspective is in order: as many as half a million New Yorkers have been infected with H1N1, and this spring in US cities, we actually saw a smaller fraction of deaths due to infectious respiratory illness, compared with 2008. Also, for reference, based on data from a few years ago, I’m guessing that any given three month period, there are between 10,000 to 15,000 deaths in New York City.
So why were ED’s swamped in May? Why are my friends still afraid to come to NYC? Dr. David Newman has some thoughts in EPMonthly:
…with constant messages of swine flu lethality on the nightly news, it is little surprise that ED’s in New York City, departments in a chronic state of over-crowding and crisis, were soon bursting at the seams with record volumes. In some institutions daily ED volumes doubled, as EP’s worked through third-world conditions of extreme crowding, questionable hygiene, extended wait times, and swarms of infectious, coughing congregates all within arm’s reach of each other.
The impact is clear: lives were lost. High quality studies have shown repeatedly that when ED’s experience crowding patients in need of rapid, high intensity care are identified later, treated more slowly, and devoted fewer resources. Mortality goes up during crowding in virtually every condition that has been studied, including MI, sepsis, and others. The irony is stark: Once a critical mass is reached, the more that come to be saved, the fewer we can save.
…The overall management of information during the swine flu of 2009, despite some progress in our access to information, was misguided and dangerous. Frantic media outlets drove a nation to fabricated fears, while state-level institutions not only failed to contain or counteract these messages, but also used expensive, fruitless, prescription-only pills, available to most only in their local ED’s, as a means of false comfort. Instead of using honest information to provide safety, comfort and education, the approach created panic, cost money and resources, and took lives.
All of this was preventable and is reversible for the future. There is no reason why the media cannot be recruited into the information dissemination process…
Unfortunately, there is a good reason why: Responsibly framing public health risks is no longer a role that suits traditional media. They’ve decided it’s just not in their interest.
I remarked on this years ago with West Nile virus, which never will never kill as many as, say, food poisoning or swimming pool accidents.
There are many factors driving the public appetite for health risk information — and that’s understandable. I think it’s even ok for news organizations to shuffle around reporting to some extent, to satiate those desires.
But what happened in NYC this spring was media malpractice — night after night, opportunities to put the risks of swine flu in perspective were passed up for breathless reporting. I recall one occasion in which a phalanx of reporters were camped outside a hospital I worked at, providing next to no detail about an infant who died it respiratory distress. It turns out this child did not have H1N1, but communicating that was not a priority — by the next day the lead story was ED’s are overcrowded and schools are closing.
EPMonthly ran a nice sidebar from Dr. Jim Augustine, enumerating the ways in which ED docs can engage the media to get the right message out.
But I’m more encouraged by approaches to bypass traditional media and reach patients directly. Yesterday I heard some encouraging news from the CDC: their emergency twitter feed has over 500,000 followers. Millions saw their videos. This is amazing reach, for public health communication.
It wasn’t enough to help ED’s this spring. But individual hospitals and the CDC is ramping up their use of social media, even as traditional news sources decline in influence. It’s really the first good viral news I’ve heard in a while.
*This blog post was originally published at Blogborygmi*
July 27th, 2009 by DrWes in Better Health Network, Health Policy, News
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Yesterday in our cath conference, we discussed the substudy from the prospective randomized trial called PREVENT-IV just published in the New England Journal of Medicine. That study evaluated the major adverse cardiac event rates of minimally invasive vein harvesting compared to open vein harvesting prior to coronary bypass surgery.
I was surprised to see that minimally-invasive vein harvesting had a higher combined complication rate of death, myocardial infarction (heart attack) and need for revascularization in the patients who received vein grafts harvested by the minimally-invasive technique. Following the presentation of the data, our surgeons were asked why this might be the case. While none knew for sure, they postulated that the art of harvesting vein-conduits using endovascular techniques might play a role (it’s more difficult), or the effects of the thrombolytic state induced by on-pump bypass vs. off-pump bypass might create the discrepency in post-surgery vein survival, since patients are less likely to develop clinical thromboses in the post-open chest bypass population.
So this morning, I was surprised that President Obama toured Cleveland Clinic yesterday and had such an up-front experience with minimally-invasive robotic surgical techniques for mitral valve repair that hardly represents mainstream American health care. While the marvels of the technology cannot be disputed, like the endovascular vein harvesting study above, might we find that robotics could be as deleterious to patients compared to open chest techniques? After all, these techniques have yet to be compared in multi-center trials to more conventional open techniques for mitral valve repair. But more concerning as we move forward is this question: will academic centers be granted more funds to test comparative effectiveness research for robotics at the expense of front-line American health care? Surely, this won’t be, will it?
Probably.
But when I see pieces like this I wonder why the article does not question the cost and risks of this technique compared to conventional open-chest procedures, especially in this era of touting the need for health care cost containment. How much is this piece about the marketing of this technique to the community (for financial gain) or to the President (for obtaining grants or political favors)?
Perhaps we should ask ourselves how many of the physicians and surgeons at Cleveland Clinic stand to earn a seat on the proposed MEDPAC board that will determine if Congress will approve payment for robotic techniques even when few data exist to show their superiority over conventional techniques.
Now that might make for some really interesting reading.
*This blog post was originally published at Dr. Wes*
July 27th, 2009 by Dr. Val Jones in True Stories
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Regular readers of Better Health will recall my personal frustration that my mother-in-law received 2 months of physical therapy, a head CT, and extensive blood testing in response to a shingles outbreak that I was able to diagnose easily over the phone.
The misdiagnosis that resulted in chronic post-herpetic neuralgia and a $10,000 waste of resources, has continued to vex me. After Mrs. Zlotkus and I realized what was going on, I outlined for her the usual treatment regimen for shingles pain – explaining that most people needed a fairly high dose of the nerve pain medicine before they experience any relief at all, and to make sure her doctor gave her an adequate dose before deciding whether or not it worked.
And you can guess what happened next.
Mrs. Zlotkus was seen by a young and inexperienced neurologist who insisted on giving her a very tiny dose of the nerve medicine (it has an excellent safety profile even at very high doses). Of course, it didn’t help. She was given 100mg twice a day (where shingles sufferers often need as much as 1800mg/day) with instructions to return in a few weeks. The doctor also told her that she “couldn’t be sure the pain was due to shingles since she hadn’t seen the original rash.”
That’s like an ER physician saying to a trauma victim that they can’t be sure of the cause of the injuries because they didn’t witness the car accident.
At that point I instructed her to find an experienced pain management specialist who’d know how to titrate her medication appropriately – and who might even be able to do a nerve block to get her some immediate pain relief.
Luckily, Mrs. Zlotkus “knew somebody who knew somebody” and was able to make an appointment the next day with a senior anesthesiologist experienced in nerve blocks. The pain management physician knew just what to do, administered the nerve block, increased her medication dose, and sent her on her way. She experienced immediate relief of her symptoms and felt like a new woman.
If Mrs. Zlotkus had gone directly to the anesthesiologist in the first place, she might have saved herself months of agony and a $10,000+ bill to Medicare. (Better yet she would have gone to her PCP when she first noticed scabs on her scalp and he would have prescribed an anti-viral medicine that could have aborted the entire pain syndrome.) But how was she to know which provider was right for her? How could she know that her neurologist was prescribing her the wrong dose of pain medication, and that a nerve block might solve all of this nicely. Without the correct diagnosis, a cascade of wasted resources and personal suffering ensued. Without me nudging her in the right treatment direction – perhaps she’d still be doing neck stretching exercises in physical therapy?
I am a fan of the “medical home” concept as described by the AAFP and wonder if it could have made a difference in Mrs. Zlotkus’ care:
“In this new model, the traditional doctor’s office is transformed into the central point for Americans to organize and coordinate their health care, based on their needs and priorities. At its core is an ongoing partnership between each person and a specially trained primary care physician. This new model provides modern conveniences, like e-mail communication and same-day appointments; quality ratings and pricing information; and secure online tools to help consumers manage their health information, review the latest medical findings and make informed decisions.
Consumers receive reminders about necessary appointments and screenings, as well as other support to help them and their families manage chronic conditions such as diabetes or heart disease. The primary care physician helps each person assemble a team when he or she needs specialists and other health care providers such as nutritionists and physical trainers. The consumer decides who is on his or her team, and the primary care physician makes sure they are working together to meet all of the patient’s needs in an integrated, ‘whole person’ fashion.”
In summary, there’s a lot of waste in our medical system caused by a lack of coordination of care, hasty diagnoses, and defensive medicine. Even the most common diagnoses (like shingles) can end up setting off a chain reaction of over testing, incorrect treatment and personal suffering. We need an “OnStar” system for healthcare – a way to help patients navigate their way to the right care at the right time. The medical home model is as good a GPS system as any… so long as the primary care physician at the center of the coordination of care is not so rushed that she can’t do her job properly. And that’s the secret to making the medical home work – giving the doctor enough time to unravel the problems at hand and figure out the best next steps in care. If we get this right, we can probably say goodbye to CT scans for shingles.
July 27th, 2009 by EvanFalchukJD in Better Health Network, Health Policy
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Gary Schwitzer links to a Business Week article that says health insurance is a very uncompetitive market. Schwitzer notes this hasn’t gotten much attention, and wonders if it is a reason why health insurance premiums keep going up.
It is – and it isn’t. As with most things in health care, there’s more to it than it seems.
Business Week and Schwitzer are right that the market for health insurance is not especially competitive. Most states have one or two dominant health insurers, and a number of other much smaller players. The smaller insurers are often at a big disadvantage. I blogged about this a couple of months ago.
But the question of the cost of health insurance is something that mostly affects small employers – the companies that employ some 55 million Americans.
As companies get bigger, they minimize their exposure to the insurance market. Mid-sized employers (between about 500 and 2,500 employees) buy so-called “stop loss” coverage. Under these plans, they self-insure for some of the risk, and buy coverage for unexpectedly high expenses. It’s sort of like a high deductible plan, except it’s for the company. That market is, in fact, highly competitive, and serves many of the 14 million Americans who work for companies of this size.
Really big companies – which employ 43 million Americans – don’t buy health insurance at all. They hire a health plan to administer their expenses, but have completely opted out of the health insurance market.
So is the uncompetitive health insurance market driving health care premium increases?
It doesn’t help, but there here are three other things that we don’t talk enough about that are driving these increases:
1. State coverage mandates. Each state requires that insurers who wish to sell there comply with a huge variety of coverage mandates. In fact, there are nearly 2,000 mandates, some of which add significant costs to health insurance. Adding new mandates is a regular activity of state governments, based on the political clout of patient groups, pharmaceutical companies and others. State governments have had an important role to play in driving premium increases.
2. Guarantee issue requirements. The other thing some states have done is outlaw medical underwriting. This means that if an uninsured person gets diagnosed with an illness, he can just go out and buy an insurance policy and, for the cost of an annual premium, get all the care he needs. He can even cancel the policy after he’s done being treated, and buy one again if he gets sick again. There may be valid public policy reasons to make health insurance guarantee-issue. But the reality is that insurers have to add in additional premium to account for the fact that their risk pool includes in it much more costly individuals than otherwise would. There is no free lunch.
3. Other cost-shifting. Studies show that tens of billions of dollars a year of uncompensated health care to the uninsured is provided by medical providers. They try to offset these costs by negotiating higher payment rates from private insurers. The same is true for government-funded programs. As these programs have attempted to control costs by simply paying less, providers have tried to recoup those reductions through higher fees to health plans. In each case, the ultimate cost is passed on to the consumer. Some groups think this kind of cost-shifting adds 5-10% to annual premium rates.
There are, of course, lots of other reasons for the rapidly increasing health insurance rates. These are few of the less discussed that we ought to talk about more.
*This blog post was originally published at See First Blog*
The following is a message that I received from a reader:
