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The Case Of Two Accidental Suicides

July 9th, 2009 by DrRob in Better Health Network, True Stories
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My worst night as a doctor was during my residency.  I was working the pediatric ICU and admitted a young teenager who had tried to kill herself.  Well, she didn’t really try to kill herself; she took a handful of Tylenol (acetaminophen) because some other girls had teased her.

On that night I watched as she went from a frightened girl who carried on a conversation, through agitation and into coma, and finally to death by morning.  We did everything we could to keep her alive, but without a liver there is no chance of survival.

Over ten years later, I was called to the emergency room for a girl who was nauseated and a little confused, with elevated liver tests.  I told the ER doctor to check an acetaminophen level and, sadly, it was elevated.  She too had taken a handful of acetaminophen at an earlier time.  She too was lucid and scared at the start of the evening.  The last I saw of her was on the next day before she was sent to a specialty hospital for a liver transplant.  I got the call later that next day with the bad news: she died.

The saddest thing about both of these kids is that they both thought they were safe.  The handful of pills was a gesture, not meant to harm themselves.  They were like most people; they didn’t know that this medication that is ubiquitous and reportedly safe can be so deadly.  But when they finally learned this, it was too late.  They are both dead.  Suicides?  Technically, but not in reality.

For these children the problem was that symptoms of toxicity may not show up until it is too late.  People often get nausea and vomiting with acute overdose, but if the treatment isn’t initiated within 8-10 hours, the risk of going to liver failure is high.  Once enough time passes, it is rare that the person can be cured without liver transplant.

Acetaminophen overdose is the #1 cause of liver failure in the US.  According to a Reuters article, there are 1600 cases of liver failure from this drug per year (2007).  This is a huge number.  In comparison consider that the cholesterol drug Cerivastatin (Baycol) was withdrawn from the market when there were 31 deaths from rhabdomyalysis (severe muscle break-down, which is far more common than liver failure in these drugs).  These happened mainly when the drug was used in combination with another cholesterol drug.

Should the drug be pulled from the market?  No, it is safe when used properly.  The toxic dose is generally 10 times the therapeutic dose.  My complaint is not that they have dangerous drugs available; ALL drugs should be considered dangerous.  Aspirin, decongestants, anti-inflammatories, and even antacids can be toxic if taken in high dose.  The problems with acetaminophen stem from several factors:

1. Most people don’t realize the danger.
2. There has been very little public education and no significant warning labels on the packages.
3. The drug is often hidden in combination with other drugs, including prescription narcotics and over-the-counter cold medications.  This means that a person can take excess medication without knowing it.

I would advocate putting warning labels on medications containing this drug.  I am sure this doesn’t thrill the drug manufacturers, but the goal is not to make them happy.  I have thought this since that terrible night during residency.  If there was such a warning, perhaps she wouldn’t have died.

It seems a bit silly that this action by the FDA is coming after their pulling of children’s cough/cold medications. Those drugs have very small numbers of true harmful overdoses.  The reason they were pulled was probably more that they didn’t do anything over the fact that they were dangerous.  Acetaminophen, on the other hand, can be deadly.

Just ask the parents of my two patients.

*This blog post was originally published at Musings of a Distractible Mind*

The Physical Exam Of The Arms, Part 1 (Or, Dr. Rob Drinks And Blogs)

June 30th, 2009 by DrRob in Better Health Network, Humor
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Yes, it’s time for another installment of my series on the physical exam.  The goals of this series are:

1. To educate my readers on the intricacies of the physical exam.
2. To teach the anatomy and physiology as it relates to different parts of the human body.
3. To delight my readers with my wit and fine prose.
4. World peace.

So you see, through my hard work and persistence (writing almost 30,000 words about the physical exam so far), I have come nowhere near any of these goals.  In fact, I have made absolutely no progress toward world peace.  I think I’ve been banned in Iran for using the word “Shuttlecraft” too many times.

Maybe I just need some new goals.  How about these:

1. To irritate my high school English teachers.
2. To cause at least 200 people to waste time that they could have spent watching Oprah.
3. To make sure Canada stays north of us and does not sneak to Florida.
4. To put those pesky French people in their place.

Yes, I think those are much better goals.

Extremely Upper

Our journey over the human body has now led us to the long things that stick out of the top of your torso that have those grabby things on the ends.  We doctors call these things arms. There are some hoity-toity doctors who call them the upper extremities. These are the doctors you don’t want to invite to dinner, as they will probably tell you disgusting scientific facts about the food you are eating.  Consider yourself warned.

The exam of the arms is usually only referred to vaguely during routine exams.  Most docs don’t deal with the arms unless they pick up subtle clues that are discovered only by trained professionals, like when the patient says “I’m having problem with my arms”.  We doctors are proud of our mad skills.

What I am driving at is that the arm exam is a problem-oriented exam.  If you have a boo-boo, the doctor looks at it and sees if a kiss will make it better.  If a kiss doesn’t work, usually an anti-inflammatory will (but we’ll get to that later).  And boo-boo problems with the arm are usually specific to the longitude and latitude on the body.  So today we will discuss the shoulder.

The Shoulder

The shoulder is a joint – meaning, it is a place where your body bends.  Without joints, your arms would be unwieldy and you’d whack everyone who came near to you.  Not only that; it would also make it impossible to put on deodorant.  So between whacking people and offending them with your odor, a jointless existence would truly be a hard one.  We all should thank our joints more often.

There is not a more complex joint in your body than your shoulder.  Here are some amazing facts about the shoulder:

• There are three bones that are involved in different types of movement: the collarbone (clavicle), shoulder blade (scapula), and humerus (not humorous).
• There are at least 18 muscles that are involved in shoulder movement.  Two of them have the word “rhomboid” in them.  I like the word “rhomboid.”
• When people say the word “shoulder,” they may be referring to the joint, and they could be referring to the top part of their torso – between their neck and shoulder joints.  This is a sad testimony to the English language and just serves to make the jobs of medical professional all the harder.
• The word “shoulder” rhymes with a lot of of words and so is very useful in poetry.  For instance:

You shouldn’t have told her that she’s looking older
She wants you to hold her with arm on her shoulder
And go get the folder that llamas once sold her
But there on the boulder the weather is colder.
A fine Jell-O mould or perhaps something bolder
Has rocked her and rolled her but never controlled her
So anger may smolder at cellular slime mold or
Other thingies, sort of.

See?  Pretty amazing, isn’t it?  Try doing that with “elbow!”  Perhaps Dino could write a haiku about it.

So it should not be seen as a coincidence that the shoulder has by far the largest range of motion of any of the joints in the body.  This makes things very confusing for medical students when they have to describe the motion, as the joint doesn’t follow any of the rules the other joints have agreed upon.  Most joints can be bent (flexed) and straightened (extended).  Some joints (like the wrist) can be hyperextended and rotated as well.  All the other joints are content with these motions.  Is this good enough for the shoulder?  Not even close.

Here are the basic movements of the shoulder:

1.  Flexion – moving the arm forward toward the chest.

2.  Extension – moving the arm toward your back.

3.  Abduction – Being picked up by aliens and brought to their mother ship.  (This also refers to lifting your arms up from your sides).

4.  Adduction – Bringing your arms down back to your sides

5.  Rotation – Turning the arm around the axis of the humerus bone.

I have suggested a few more motions that may be added to the roster:

6.  Subflaxion – What you have to do to your shoulder to get your elbow in your ear.

7.  Soufflétion – When your shoulder is mixed with eggs and baked at 400 degrees.

8.  Mallardduction – When your shoulder gets down.

So far the shoulder committee hasn’t answered my mail.  I’m not sure why.

But really, the shoulder is very confusing to many medical professionals.  The range of motion is so great that it blurs the lines between the typical movements.  For instance, adduction is supposed to be when the limb is moved toward the body’s midline.  The shoulder makes this difficult.  When you put your arm by your side and when you raise it over your head, you move it toward midline.  Both could be considered adduction.  The same is true with flexion and extension – when is the shoulder joint opened up and when is it closed?

Really, in this modern time we should give up this archaic nomenclature and instead use a GPS device to determine shoulder position.

Wow.  1000 words already and I haven’t gotten to the actual exam.  I’ll give it a rest now and let you ruminate on words that rhyme with “elbow.”

I probably should sober up as well.

*This blog post was originally published at Musings of a Distractible Mind*

The Importance Of Medical Blogging

June 25th, 2009 by DrRob in Better Health Network, Opinion
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I was looking through an article in Time Magazine recently and came across an article about healthcare reform.  It spoke of the daunting task ahead and went through a list of the people at the table in the process of creating change.  The list included politicians, hospital corporations, pharmaceutical companies, insurance companies, and lobbyists from certain large special-interest groups.  Notably absent from the list was physicians and “normal” patients.  I commented about this in a conversation with Val Jones, MD, and she said: “If you aren’t at the table, then you’re on the menu.”

She’s right.  Up to now, the interests of the people who matter most – the doctor and patient in the exam room – were largely unheard.  Folks said they knew our needs, but they all had their own agendas and so often got it wrong (either out of ignorance or out of self-interest).  Even the organizations that are supposed to represent my needs, the AMA and the specialty societies to which I belong, are not composed of folks who spend most of their time in the exam room; they are people who have either retired to spend their time in Washington, or are full-time smart people (they know lots about other people’s business).  There are very few people at the table who regularly see patients.  There are also very few who represent patients without a particular axe to grind (elderly, people with chronic disease or disabilities).

But healthcare is about what goes on in the exam room.  The entire point of healthcare is health care; it is about the care of the patient.  It isn’t about the business, the drugs, the delivery system, or the insurance industry; it’s about optimizing how the system makes sick people better and keeps better people from becoming sick.  Everything else is a means, not an end.

But those of use who are in the exam room are soon to be served up on the menu for the sake of political gain and special interest clout.  They may or may not have a good plan, and they may or may not have good intentions.  But they definitely do not have an understanding of what really goes on and won’t be affected much by the decisions they make.  They are serving up a dinner of food they don’t know about and they won’t have to eat what they cook.  How can they make good decisions?

A step in the right direction would be to listen to bloggers.  As opposed to the lobbyists and pundits inundating Washington, we actually do healthcare.  The doctor and patient blogs on the web represent the interests of the people who are in the middle of the healthcare universe.  This universe doesn’t have Washington DC at its center, it has the patient and those who care for him or her.

A good parallel is the crisis in Iran.  There are reporters and politicians who say they know what it’s all about – and in some ways they do – but the voice of the people living in Iran are crucial to understanding what is going on.  Why are there riots?  Ask a rioter.  Was there rigging of the election?  Ask someone who was there to witness the process.  The people who are on the ground should always be listened to.  They don’t give the entire perspective, but getting a true perspective is impossible without talking to them.

Don’t just listen to me; I represent a specific point of view, and don’t represent that of patients or specialists fully.  Don’t just listen to patient blogs, as they often don’t have a clear understanding of the business of medicine or the complex medical realities (although I know some of them do know an awful lot).  We need to force ourselves to the table.  We need to give perspective that has previously been invisible.

Blogging matters because it gives perspective that could never come from anywhere else.  Blogging is the journalistic equivalent of democracy, giving the average person a chance to make their voice heard.

In July, a group of us medical bloggers will be going to Washington to do what we can to make our voice heard (thanks to Val Jones’ hard work).  Maybe it won’t make a difference; but at least we won’t be invisible any more.

*This blog post was originally published at Musings of a Distractible Mind*

Electronic Medical Records: What Parts Should Patients Be Able To Alter?

June 22nd, 2009 by DrRob in Better Health Network
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I have heard a lot of talk about ownership of medical information.  Bloggers like e-Patient Dave, and Robin are strong advocates for patient ownership of their information.  To be truthful, I get nervous when I hear people saying they own something I have in my possession (and I’ve blogged about this).  The charts in my office are mine, right?  How can I create something and have it not be mine?

I carried this unease with me into the exam room recently.  Thinking about the ownership of medical information, I opened a patient chart.  The vital signs were already in, and I started in on the HPI (the patient’s story as to why they are there).  I do this by asking questions: When did it start?  How long did it last?  What did it feel like?  What did you take?  Did you have other symptoms with this?  How bad was it?  Have you ever had this before?

Hmmm…. Whose information is this?

Then I went on to the review of systems.  We have the patients circle symptoms on a laminated sheet and I discuss what they circled.

“You have some chest pain?”

“Well, it was a sharp pain that happened when I coughed.  Is that bad?  Could it be my heart?”

We then go into a discussion about chest pain and what to look for.

I put down the information the patient has given me and think a little more.  The patient’s information?

Then I get frustrated.  The past medical history hasn’t been updated recently, she’s been in the hospital and most of the information about this is not in the chart.  The medication list is not accurate.  The information about her family, lifestyle, and habits are incomplete and I don’t know when they were last updated.  I sigh, then try to fill in the gaps as best as I can by asking her questions without betraying my lack of confidence in our record.

We have a meeting of our IT team after this, and I am thinking about this encounter.  We are about to roll out a patient portal where patients will be able to log onto our website securely and fill out patient demographics, request refills, and get appointments.

“What information in the record would the patient be best to be in charge of?” I ask.  By being “in charge” I mean that the patients would have actual control of this information and we would read it.  I tell them about my experience and frustrations and we make the following list:

• Marital Status
• # Children
• Job/School info
• Home DM monitoring, weight, BP
• Address, phone, e-mail address
• Family history

Then I ask, “What information in the record could the patient contribute directly to?”  By this I mean that they would see the information as it is in there and be able to suggest changes or additions, but would not be able to actually change themselves.  Here’s what we came up with:

• Smoking, alcohol
• Medication List
• History of visits to other medical providers, consultant names, etc.
• Review of systems prior to visit
• Surgical history

We want to be able to assemble this information so that it is in a format that is readable to us and fits our needs, but the patient would have the ability to take this data information and perhaps download it to organize as they wish.

“So what information should they have access to?” I ask, referring to information they can see, download, and organize as they wish, but not add or subtract to.  Here is that list:

• Upcoming tests needed (Colonoscopy, etc)
• Immunizations
• Lab results
• Visit schedule – past and present
• Previous vital signs
• Recommended schedule based on their diseases
• Problem list?

Finally, we discuss what is our own information that the patient only has access to if they request it.  This is information that either will give them too much information (our thought process and remote concerns) or even things that we don’t want them to see (suspicions about truthfulness or worse).  Here is this list:

• Perhaps the problem list – if it contains things like anxiety, suspected abuse, or private things the patient has told us.
• The HPI often has information that is potentially sensitive.  People have to feel free to tell us things, and having that information be back in the face of the patient on the Internet (albeit a secure site) goes a bit too far.  Who knows if a family member can access it?  What about teens?  It’s just too complicated.
• Part of the assessment and plan is often conjecture and reminders to ourselves to pay attention to things in the future.  If a person has weight loss, we may keep cancer in the back of our minds.  If a person is asking repeatedly for narcotics, we may write down suspicions that  bear watching in the future.  We have to have a place where we can put things down and know they are for our own eyes only.

The last list is the shortest.  Yet the current state of things is that the entire chart falls into the last category.  This not only leaves the patient in the dark, it makes it so we have to do a whole lot of unnecessary work that the patient would do much better at (and without costing us a dime).

I think this is the sweet spot.  This is the way the medical record should be in the future.  It should be a shared venture – not just between PCP and patient, but also including other providers.  For care to truly move forward we have to dream about what it could be.  Our office now has this as the vision for where we want to head.  I know my patients will be thrilled, and I am pretty sure I’ll have a lot less frustration in the exam room.

*This blog post was originally published at Musings of a Distractible Mind*

Healthcare Reform Views From A Flaming Moderate

June 15th, 2009 by DrRob in Better Health Network
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I am a flaming moderate.  Yes, I know that is an oxymoron but the fact remains that I am both passionate and moderate in my political opinions.

And I am in the mood to rant, so beware.

Living in the deep south, I often seem like a radical communist to those I see.  I frequently get patients asking questions like “So what do you think about Obama’s plans to socialize medicine?”, or “I wanted to get in here before Obama-care comes and messes things up.”  I usually smile and nod, but find myself getting increasingly frustrated by this.

The house is burning down, folks.  Healthcare is a mess and desperately needs fixing.  How in the world can someone cling to old political yada-yaya-yada when people are dying?  I am not just talking about the conservatives here because to actually fix this problem we all have to somehow come together.  A solution that comes from a single political ideology will polarize the country and guarantee the “fix” to healthcare will be one constructed based on politics rather than common sense.

No, this doesn’t frustrate me; it infuriates me.  The healthcare system is going to be handed over to the political ideologues so they can use it as a canvas for their particular slant.  In the mean-time, people are going to be denied care, go bankrupt, and die.  Yes, my own livelihood is at stake, but I sit in the exam room with people all day and care for them.  I don’t want to be part of a system that puts ideology above their survival.

So here is what this radical moderate sees in our system:

1. The payment system we have favors no one. Every single patient I see is unhappy with their health insurance to varying degrees.
2. Stupid and wasteful procedures shouldn’t be reimbursed. This is business 101; if you don’t control spending, you will not be able to sustain your system.  This means that we have to stop paying for procedures that don’t do any good.  Some will scream “rationing” at this, but why should someone have the right to have a coronary stent placed  when this has never been shown to help?  Why should we allow people to gouge the system for personal gain in the name of “free market”?  I got a CT angiogram report on patient today who has fairly advanced Alzheimer’s disease.  I twittered it and the Twitter mob was not at all surprised.  These things happen all the time.  The procedures do no good and cost a bundle.  The procedure done today probably cost more than all of the care I have given this patient over the past 5 years combined!
3. The government has to stop being stupid. Why can’t I give discount cards to Medicare patients?  Why can’t I post my charges, accept what Medicare pays me, and then bill the difference?  The absurdity within the system is probably the best argument against increased government involvement.  Who invented the “welcome to Medicare physical??”  I never do it because the rules are utterly complex and convoluted.  If the rules can be this crazy now, how much worse will it be when the government takes over?  If my medicare patients are confused now, how much more will we all be if the government grabs all of the strings?
4. The money is going somewhere. In the past 10 years, my reimbursement has dropped while insurance premiums have skyrocketed.  There are more generic drugs than ever and I am no longer able to prescribe a bunch of things that didn’t get a second-thought 10 years ago.  Hospitals stays were longer and procedures were easier to get authorize.  So where is the money going?? We do know the answer to this question – there is no single culprit.  Drug companies were to blame for a while, but now they are going to the dogs; and yet the rates aren’t dropping.  The real problem is that there are far too many people trying to capitalize on the busload of money in healthcare.  Shareholders, CEO’s, and simple corporate greed has bled money out of the system like a cut to the jugular.
5. Docs have to stop being idiots. We like our soap boxes to rant against EMR, malpractice lawyers, drug companies, and insurance companies.  We stand on different sides yelling our opinions but don’t come up with solutions.  Instead of doing what is right for our patients, we join the punching match of politics.  Is EMR implementation important?  Duh!  There is no way to fix healthcare without it.  But the systems out there are designed by engineers and administrators and don’t work in the real life.  So why can’t we computerize ourselves?  Every other industry did.  Why must we cling to the archaic paper chart because we don’t like the EMR’s out there?  Aren’t we smart people?  Aren’t we paid to solve problems?  Stop throwing darts and start finding solutions.  Med bloggers are terrible in this – they rant constantly against EMR, but don’t ever say what would work.  It’s fun to criticize, but nobody wants to propose an alternative.
6. We need to get our priorities right. Healthcare is about the health of the patient.  Yes, it is a job for a lot of people.  Yes, it is an investment opportunity.  Yes, it is a good thing to argue about – whether it is a “right” or not.  Yes, it is a major political battleground.  But in the end, these things need to be put behind what is most important.  As it stands, we are more passionate about these other things than we are about the people who get the care.  In the end it is about making people well or keeping them that way.  It is about saving lives and letting people die when it is time.  If we were all half as passionate about what is good for patients (and we are all patients) as we are about these other issues, we wouldn’t have half of the problems we have.

As a flaming moderate I get to offend people on all sides.  We need to fix our system.  It is broken.  It is not a playground for those who like to argue.  It is not a place to be liberal or conservative.  This is our care we are talking about, not someone else’s.  The solution will only come when we all come to the table as potential patients and fix the system for ourselves.

Is it easy?  Heck no.  This rant is not meant to show I am smarter than the rest of you; it is meant to get all of us away from the other issues that make any hope of actually fixing our problem remote.  Given the fact that we all are eventually patients, our political posturing and plain stupidity may come back to haunt us.  No, it may come back to kill us.

*This blog post was originally published at Musings of a Distractible Mind*