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Wilderness Medical Society Publishes Prevention And Treatment Tips For Altitude Sickness

Led by Andrew Luks MD and his colleagues, the Wilderness Medical Society has published Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness (Wild Environ Med 2010:21;146-155). These guidelines are intended to provide clinicians about best evidence-based practices, and were derived from the deliberations of an expert panel, of which I was a member. The disorders considered were acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). The guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations for their roles in disorder management. The guidelines also provide suggested approaches to prevention and management of each disorder that incorporate the recommendations.

In outline format, here is what can be found in these Guidelines: Read more »

This post, Wilderness Medical Society Publishes Prevention And Treatment Tips For Altitude Sickness, was originally published on Healthine.com by Paul Auerbach, M.D..

Should Primary Care Be Abandoned?

In his last post, DrRich pointed out to his PCP friends that their chosen profession of primary care medicine is dead and buried – with an official obituary and everything – and that it is pointless for PCPs to waste their time worrying about “secret shoppers” and other petty annoyances.

It is time for you PCPs to abandon “primary care” altogether. It is time to move on.

Walking away from primary care should not be a loss, because actually, primary care has long since abandoned you. Whatever “primary care” may have once been, it has now been reduced to strict adherence to “guidelines,” 7.5 minutes per patient “encounter,” placing chits on various “Pay for Performance” checklists, striving to induce high-and-mighty healthcare bureaucrats (who wouldn’t know a sphygmomanometer from a sphincter) to smile benignly at your humble compliance with their dictates, and most recently, competing for business with nurses.

This is not really primary care medicine. It’s not medicine at all. It’s something else. But whatever it is, it’s what has now been designated by law as “primary care,” and anyone the government unleashes to do it (whether doctors, nurses, or high-school graduates with a checklist of questions) now are all officially Primary Care Practitioners.

What generalist physicians (heretofore known as primary care physicians) need to realize is that “primary care” has been dumbed-down to the point where abandoning it is no loss; indeed, it ought to be liberating to walk away from it.

The beauty is that Read more »

*This blog post was originally published at The Covert Rationing Blog*

The Bottom Line On New FDA Sunscreen Guidelines

Life is really simple, but we insist on making it complicated. -Confucius

This is certainly true of sunscreens. “Broad spectrum, UVA, UVB, avobenzone, oxybenzone, parsol, sensitive skin, titanium dioxide, SPF 15, 30, 45, 50, 55, 60, 70, 75, 100, 100+, waterproof, sweatproof, spray, cream, lotion, antioxidant…”

We spend about $700 million in sunscreens every year, and many people don’t have a clue as to what’s good or bad, or a waste of money. The Food and Drug Administration has been meaning to help you out with this problem for a while now. Actually for over 30 years (who says nothing gets done in government?). The F.D.A. has made a final decision on sunscreen labels. They’ve sought to make labels simple and accurate to help you choose the right one:

1. The sunscreen must protect against both UVA and UVB rays; that is, it must be broad spectrum.

2. To be labelled as “protecting against skin cancer,” the sunscreen must be an SPF of at least 15. The labels will likely be capped at SPF 50 because SPFs greater than 50 seem to be of little additional benefit.

3. Sunscreens can no longer be labelled as “waterproof” or “sweat proof,” as neither is physically possible, therefore, rendering the claim “misleading.” Sunscreens will be labelled as effective in water for 40 minutes or 80 minutes which is accurate and much more useful.

This simple system should help consumers make better choices, but some say the F.D.A. didn’t go far enough. They did not comment on the safety of various sunscreen ingredients. They have also not loosened up enough to allow for other sunscreens that are widely used in Europe to be sold here in the U.S.

Do you think the F.D.A was too strict or didn’t go far enough?

Photo: Wandering Magpie, Flickr

*This blog post was originally published at The Dermatology Blog*

When Is It Appropriate To Disregard Guidelines In Medical Care?

Podcast:

In an article appearing last week in the American Heart Journal, investigators concluded that if American doctors would prescribe for their patients with heart failure each of the six therapies which are most strongly recommended in current heart failure guidelines, 68,000 lives per year could be saved.

The following (for the interest of the reader, and for the convenience of any attorneys who may follow DrRich’s offerings), is an ordered list of these six proven, life-saving heart failure therapies, along with the number of American lives that could be saved each year if only American doctors would stop grossly under-utilizing them in violation of published guidelines:

  • aldosterone antagonist therapy – 21,407 lives
  • beta blockers – 12,922 lives
  • implantable defibrillators (ICDs) – 12,179 lives
  • cardiac resynchronization therapy (CRT) – 8317 lives
  • hydralazine plus isosorbide – 6655 lives
  • ACE inhibitors or angiotensin receptor blockers (ARBs) – 6516 lives

The authors, of course, are careful to point out that their analysis is based on statistical methods, and thus must be counted as merely estimates of the magnitude of the benefit that would actually occur should American doctors suddenly begin managing their heart failure patients appropriately. (Their presentation of these estimates to five significant figures implies a level of precision far in excess of what can be justified, and therefore must be an oversight not only by the authors, but also by the reviewers and the editors. But still, one gets the idea. A lot of preventable deaths are being left on the table.)

Several studies have reported, over and over again, that fewer than half of American patients with heart failure Read more »

*This blog post was originally published at The Covert Rationing Blog*

The New World View Of Coronary Artery Disease

In 2007, when the results were published from the COURAGE trial, all the experts agreed that this study would fundamentally change the way cardiologists managed patients with stable coronary artery disease (CAD).*

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*”Stable” CAD simply means that a patient with CAD is not suffering from one of the acute coronary syndromes – ACS, an acute heart attack or unstable angina. At any given time, the large majority of patients with CAD are in a stable condition.
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But a new study tells us that hasn’t happened. The COURAGE trial has barely budged the way cardiologists treat patients with stable CAD.

Lots of people want to know why. As usual, DrRich is here to help.

The COURAGE trial compared the use of stents vs. drug therapy in patients with stable CAD. Over twenty-two hundred patients were randomized to receive either optimal drug therapy, or optimal drug therapy plus the insertion of stents. Patients were then followed for up to 7 years. Much to the surprise (and consternation) of the world’s cardiologists, there was no significant difference in the incidence of subsequent heart attack or death between the two groups. The addition of stents to optimal drug therapy made no difference in outcomes.

This, decidedly, was a result which was at variance with the Standard Operating Procedure of your average American cardiologist, whose scholarly analysis of the proper treatment of CAD has always distilled down to: “Blockage? Stent!”

But after spending some time trying unsuccessfully to explain away these results, even cardiologists finally had to admit that the COURAGE trial was legitimate, and that it was a game changer. (And to drive the point home, the results of COURAGE have since been reproduced in the BARI-2D trial.) Like it or not, drug therapy ought to be the default treatment for patients with stable CAD, and stents should be used only when drug therapy fails to adequately control symptoms.

When the COURAGE results were initially published they made a huge splash among not only cardiologists, but also the public in general. So cardiologists did not have the luxury of hiding behind (as doctors so often do when a study comes out the “wrong” way) the usual, relative obscurity of most clinical trials. Given the widespread publicity the study generated, it seemed inconceivable that the cardiology community could ignore these results and get away with it.

But a new study, published just last month in JAMA, reveals that ignore COURAGE they have. Read more »

*This blog post was originally published at The Covert Rationing Blog*

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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