September 9th, 2008 by Dr. Val Jones in Uncategorized
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I was catching up on my Wall Street Journal blog reading, when I came across a post about a physician who was sued for prescribing painkillers to a patient who proceeded to crash her car. The crash killed a pedestrian, and the victim’s wife is now suing the driver’s doctor. Obviously, this case sends chills down physician spines – as it seems that we are now held responsible for patient behavior outside of the the doctor-patient relationship or hospital setting.
Beyond the outrageousness of the case itself, is the sad subtext found in the comments section. Physician after physician respond that they are leaving medicine or have ceased clinical practice. They say that they’d never allow their children to become doctors, and that no amount of compensation is worth the risk and sacrifices of a career in medicine. It’s really depressing to read about such low morale.
For those physicians remaining – I do see a couple of bright spots. First of all, concierge medicine (or “micropractices” where patients pay cash for services) permits the doctor to see fewer patients at the same salary. Removal of the administrative headaches associated with insurance reimbursement as well as the frenetic pace of “volume uber alles” dramatically improves quality of life and patient satisfaction. The physicians I know who have switched to cash-only businesses are very happy.
Second, working as a physician for the US military has one major advantage: you cannot be sued. The idea is that military physicians do their very best to take care of the troops, but it is recognized that military personnel are at great risk for physical harm due to the nature of their job. The Feres Doctrine stipulates that military personnel cannot sue the government for perceived (or real) poor medical outcomes related to active duty. In cases of medical negligence (for veterans and off-duty military personnel), the government may be sued, but not the individual physician.
So, if the tyranny of medical malpractice attorneys becomes unbearable, one might consider practicing in a VA or military hospital. Sounds crazy, I know… but it’s worth a look! Of course, a better solution would be for the next administration to take on Tort Reform in a serious way, and promote tax breaks and facilitate health savings accounts for Americans who’d like to have more control in how they spend their healthcare dollars. Maybe then they could sign up for an affordable concierge practice and at last both doctors and patients could be happy again?
What do you think?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 4th, 2008 by Dr. Val Jones in Uncategorized
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This interview is a continuation from part 1.
Dr. Val: How did Simon contract the MRSA infection?
Dr. Macario: That will remain the biggest mystery of my life. No one knows how he picked it up. In Simon’s case there was no entry via the skin – he had no cut or boil or surface evidence of infection. He contracted the community associated strain of the bacterium, which is much more virulent than the kind people get in hospitals. It seems that the MRSA superbug somehow got into his body via his lungs. It’s possible that he touched something with MRSA on it and put it in his mouth and then breathed it in. Unfortunately, there’s just no way to know where he got it.
Dr. Val: How many children die of MRSA infections/year in the US?
Dr. Macario: According to the Centers for Disease Control and Prevention, in 2005, nearly 19,000 Americans died from MRSA infections. During the same year, there were 134 cases of MRSA in children. Actually, more people in the US die from MRSA every year than from AIDS.
Dr. Val: Tell me what you’re doing to promote awareness of MRSA.
Dr. Macario: I have a Ph.D. in Public Health, and when I received the autopsy report stating that Simon’s death was caused by community-acquired MRSA, I was dumbfounded. I hadn’t even heard of MRSA before. In fact, in my career in Public Health I thought that infectious diseases were no longer much of an emphasis because of the terrific job we’ve done in eradicating most diseases through vaccine programs and antibiotics. I assumed that lifestyle issues (nutrition, physical activity, early detection, and safety precautions) would be the focus of my career.
It was a real eye-opener to me to live through the loss of a child to a menace I thought we had under control. Sixty years ago families had large numbers of children, knowing that some would be lost to infectious disease. That just isn’t the way we think anymore. But MRSA is a threat that could essentially take us back to a time when Americans died of infections quite commonly. MRSA is a superbug that is highly resistant to most antibiotics we have. It’s only a matter of time until it’s resistant to everything.
I’ve begun working half-time with Dr. Robert S. Daum at the MRSA Research Center at the University of Chicago Medical Center, Department of Pediatrics, Section of Infectious Diseases (Chicago, Illinois). Not only are we studying how contagious MRSA is (in home and jail settings), we are also studying the most effective way to treat MRSA infections.
Dr. Val: What should doctors know about MRSA and children?
Dr. Macario: There are 506 new drugs approved by the FDA for development… only 6 are new forms of antibiotics. That’s because the antibiotics are not so profitible. Antibiotic customers are short term users – they need the antibiotic for a short time and then they’re healed. Contrast that with a drug like Lipitor, something that people need to take every day for a lifetime, and you’ll see why statins are more of a priority for drug company development than a new antibiotic that could combat MRSA.
Doctors need to realize that MRSA is a growing threat, and we may not have a good treatment for it in the near future. There is a new strain of MRSA (the “community associated” strain) that can be found anywhere – schools, homes, locker rooms, and gyms. This strain is more virulent and more resistant to antibiotics than anything we’ve seen before.
Dr. Val: What advice do you have for parents to protect their children from MRSA?
Dr. Macario: Wash your hands frequently and thoroughly, clean surfaces with bleach, don’t share personal items like towels and razors. Parents should NOT run to antibiotics for any possible illness their child may have. Don’t use antibiotic soaps. Antibiotics should be considered the absolute last resort. If we keep using them for viral illnesses or when we don’t really need them, we’ll just fuel the drug resistant MRSA.
Dr. Val: What’s the most important thing you’d like to tell Americans about MRSA?
Dr. Macario: This new strain of MRSA (community associated MRSA) can affect anyone. Young, old, middle aged, healthy or sick. It can attack a person as healthy as basketball star Grant Hill. It happened to my healthy baby, and it can happen to your family. People must view antibiotics as a sacred last resort to treating disease. If they overuse and misuse them, MRSA and other resistant strains of bacteria will continue to mutate and become even more prevalent and dangerous.
My husband and I are both highly educated, I keep my house immaculate, I vaccinate my kids, and they never went to daycare centers. It doesn’t matter what socioeconomic strata you’re in, race, gender, ethnicity or age – MRSA doesn’t discriminate. It can happen to you.
But to leave this on a brighter note: my husband and I had another son after Simon died. His name is Dylan, and has brought a lot of joy to our lives.
***
For more information about MRSA, please check out StopMRSAnow.org
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 3rd, 2008 by Dr. Val Jones in Uncategorized
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I had the honor of interviewing Dr. Everly Macario about the the tragic death of her young son, Simon Sparrow. Simon was a healthy one and a half year-old baby who came in contact with a deadly form of Methicillin-Resistant Staphlococcus Aureus (MRSA). The bacteria got into his blood stream and ended his life just 2 days later. Everly has become a tireless advocate for MRSA awareness. This is her story:
Dr. Val: Tell me what happened to Simon.
Dr. Macario: Simon was a very healthy, breast-fed baby, born at full term with no history of illness or immune disease. When he was about 15 months old he caught what I thought was a throat infection. He wheezed a bit when he breathed so I took him to the doctor. The doctor reassured me that he seemed to have a mild case of bronchitis, and gave me some albuterol, prednisone and antibiotics.
Simon did well for a few days until he woke up on a Friday morning with a primal terrified shriek (a sound neither my husband or I had heard from Simon before) and a fever. My husband decided to take Simon to the Emergency Room immediately. Once there, the doctors ran the standard battery of tests (e.g., chest X-ray, oxygen-level test) only to speculate that he may be an asthmatic kid.
I could tell something was really wrong given how irritable Simon was… he truly was inconsolable. When my husband came to pick us up, my husband noticed Simon’s lips were blue as we were walking out the ER doors. We went back in and pointed this out to the doctors. They, once again, measured his oxygen level and informed us that he was within normal range. We then went home and gave Simon some albuterol administered via an inhaler. When we did this, Simon’s eyes rolled back into his head in such a way that really alarmed us. But, we said to ourselves, “he’ll be fine, he’s just sick like any other kid his age gets sick, it’s temporary, he’ll be fine….”
That afternoon, Simon vomited the little milk he had had that morning, and lied limply in my arms – something that terrified me as I was used to a more wiggly and restless Simon when he would get ready for a nap. He kept asking for “agua” (water in Spanish) and drank about 4 “sippy” cups of water, only to vomit all of it soon-after. I really panicked when his cheeks and forehead were cold and his lips were turning blue again. His nostrils were also flaring and he was breathing so heavily at this point that his chest was expanding and contracting “in and out” in the shape of a barrel. I called the doctor to have her hear Simon’s labored breathing, at which time she said, “Hang up and call 911.”
As soon as Simon was wheeled in to the ER, doctors hooked him up to everything imaginable (oxygen, nebulizer, IVs for medication and pain relievers). And, I kept hearing, “Your child is very, very sick. Your child is very, very sick.” At this point I became absolutely hysterical – “basket case” would be the technical term. Simon kept looking at me with his chocolately-brown eyes, and long curly eye-lashes, repeating, “Agua, agua, … agua.”I was so completely terrified and felt so utterly helpless that my reaction was to call my parents. I had to leave Simon to call them. As soon as I got off the phone I ran back to where Simon had been, only to learn he had been brought up to the ICU, where he was going to get intubated so that he could breathe more easily.
I was brought into a conference room where one of the pediatric emergency room doctors sat me down and began to tell me that Simon had an infection but the source was yet unknown. Her tone was almost too muted and the pace at which she spoke seemed very slow. From this point on, doctors kept coming in and out of the room with updates – basically, Simon had gone into septic shock and his blood pressure was dropping. One fellow who tried to be encouraging said, “Most kids leave the ICU.” It was this fellow, however, who said later that evening that she “didn’t want to lie, that Simon was going downhill.”
By the time my husband arrived and we were allowed to see Simon, I knew in my soul Simon was dead. Jim and I gathered around the bed on which Simon was lying, along with what seemed like 10 doctors, representing every specialty in medicine. The attending said that they had to get Simon on ECMO (the “heart-lung machine” or “extracorporeal membrane oxygenation”) as this was “his only chance.” I begged the ECMO expert to do what he could to save Simon.
From that point on until Saturday morning, Jim and I desperately and despairingly prayed for Simon to come out of this sepsis state somehow. Doctors came in regularly to update us but we knew the chances were not good when we heard things like, “We’re not sure if your son is going to make it at this point.”
While on ECMO, Simon became incredibly bloated and his skin turned purplish and scab-like.He had solid plasma “tears” coming out of his eyes. He did not look like Simon.
Late morning the next day, Jim and I decided to take Simon off of the ECMO machine, as he was not responding to it at all, and he was pronounced dead at 12:45 p.m. Still no precise cause of death.
Two months later, from the autopsy, we learned, as was suspected, that Simon died from “Methicillin-Resistant Staphylococcus Aureus” (MRSA), probably the “community-acquired” kind versus the hospital-based one. Neither my husband nor I had ever heard of it. MRSA is a virulent antibiotic-resistant bacterium. We have since learned that because of the over-prescription of antibiotics and the use of antibiotics in animals that we eat, we have created an environment that causes “weaker” bacteria to die off, allowing stronger competing strains to survive. MRSA is only treatable with vancomycin, that is assuming you know that is what you have contracted.
It seems unfathomable that a healthy, hearty, and beautiful little boy could have breathed in such a bacterium – one that attacked his organs by releasing lethal toxins – and in less than 24 hours was gone. MRSA took my son swiftly and totally.
***
Please see the next blog post for the rest of the interview with Dr. Macario.
Everly is a spokesperson for STOP MRSA Now.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 28th, 2008 by Dr. Val Jones in Uncategorized
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There is no doubt that vaccines are life-saving, and their development is one of the most important contributions to medical science in the past century. There are about a dozen regularly recommended adult vaccines, and kids in the US receive about 16 shots before the age of 2. New vaccines are being developed all the time.
With this year’s flu season just around the corner, a recent poll suggests that only 44% of parents have their children vaccinated against influenza. I decided to interview two pediatricians about the influenza vaccine, to find out more about it.
Dr. Ben Spitalnick is Assistant Clinical Professor, Mercer University School of Medicine, Savannah, Georgia. Dr. Stacy Stryer is Revolution Health’s pediatric specialist in private practice in Virginia. She offers a post-script at the end of the interview.
Dr. Val: What is the AAP’s current recommendation regarding vaccinating children against influenza?
Dr. Spitalnik: This is the first year that the AAP (as well as the ACIP) has recommended flu vaccination for all children age 6 months to age 18 years, regardless of whether or not they fall into the “high risk” medical categories that have been used as screening parameters in recent years. In addition, they recommend vaccination of pregnant women and all health care providers. Finally, they recommend vaccination of household contacts and out-of-home providers of all children under 5 years of age, and similar contacts of children older than 5 with high risk health conditions.
Dr. Val: What percent of parents vaccinate their children against influenza?
Dr. Spitalnik: While over 80% of parents recognize that there is an influenza vaccine available, data show that only about 44% of parents have had their child vaccinated against influenza in the past. In addition, despite the AAP’s broader recommendations regarding flu vaccination, still less than half (about 48%) plan to vaccinate against the flu this coming year. While there are plenty of possible reasons why vaccination rates are so low, health providers owe it to their patients to continue to find ways to improve delivery of and education about the influenza vaccine.
Dr. Val: What did the National Parent-Child Survey uncover about parents’ attitudes towards flu vaccines?
Dr. Spitalnik: The National Parent-Child Survey certainly provided some eye-opening data. While experts recognize that getting an annual flu vaccine is the single best way to protect yourself or your child from catching influenza, the survey shows that parents rank the flu vaccine sixth in importance to prevent the flu. Specifically, parents in this survey believe that hand washing, adequate sleep, balanced diet, avoiding sick contacts, and taking vitamins are better ways to protect against the flu. This helps emphasize the point that the health care community must continue to find ways to educate the public about influenza, and more importantly, its prevention.
Dr. Val: If someone has the flu, how can they help to prevent their child from getting it?
Dr. Spitalnik: Chances are this year, as with most years, almost every child will be in close contact with someone that has the flu. While hand washing, avoiding sick contacts, and getting adequate rest and nutrition may help against the flu, the single most effective way to prevent a child from getting the flu is having the child vaccinated. While protection after vaccination is fairly quick, it is not instantaneous, so waiting until your child is exposed to the flu is not the best approach. Instead, follow the recommendations of your health care provider and get vaccinated at the right time, and don’t wait until it may be too late.
Dr. Val: How dangerous is the flu virus to children? Are there any subgroups of children at higher risk?
Dr. Spitalnik: The flu is a significant danger to children, though the public doesn’t seem to appreciate the risk, which could be why vaccination rates are so low. While many feel the flu is nothing more than a severe form of the “common cold”, in reality it can lead to very high fever, dehydration, pneumonia, and can even be fatal. In fact, Influenza is the single leading cause of vaccine-preventable disease in the U.S., with estimates between 15 million and 60 million cases in the US a year among all age groups. Influenza leads to 200,000 hospitalizations and about 36,000 deaths a year in the U.S., mostly in infants and the elderly.
There are certain subgroups of children that are at higher risk for complications from the flu. These include children with asthma or other chronic lung conditions, certain heart diseases, patients who have weakened immune systems including HIV, sickle cell anemia, kidney disease, diabetes, and others. These are groups that we offer flu vaccines to first, when the vaccine is in short supply. The list above is not comprehensive, and any patient with a specific question about their own child’s medical conditions should contact their physician.
Dr. Val: Does the recent resurgence of measles tell us anything about parents’ attitudes towards childhood vaccinations?
Dr. Spitalnik: Yes, it certainly does. Cases of measles in the U.S. are at their highest level in more than a decade, with half of these cases in patients from families that rejected the measles vaccine. Many of the other cases were from exposures to these unvaccinated patients, but in children who were not yet old enough to receive the measles vaccination. I know that some physicians are asking parents (who refuse to vaccinate their children) to find a new doctor. They’re worried that other families’ infants may be exposed in the waiting room to kids with measles.
While some parents are refusing vaccines for their kids, there is impressive data from Japan clearly demonstrating the life-saving value of vaccinating children against influenza. In the 1960’s, the death rate in Japan from pneumonia and Influenza (P&I) was approximately 10 per 100,000. Over the next decade flu vaccination in the schools was made optional and then mandatory, and by the 1980’s the death rate from P&I showed a steady decline, eventually down to 4 in 100,000 – a significant reduction. In 1987, however, parents were allowed to refuse vaccination, and in a decade death rates quickly rose back up to near their 1960’s levels.
There is clearly more we need to do to help educate our patients about vaccines, not just with influenza. Specifically, however, flu vaccine education has its own hurdles, and I hope this year we all do a better job protecting our patients from this dangerous disease.
Dr. Val: What’s the most important thing that parents should know about the flu vaccine?
Dr. Spitalnik: If I had to choose one it would be that the flu vaccine, in any form, is the single best way to protect your child from the flu, which can be a serious threat to their health, and is now recommended for ALL children age 6 months to 18 years.
In addition, parents need to know that the flu vaccine is better than ever this year: First of all, there does not appear to be any shortage of supply. Second, all 3 strains of the vaccine have been changed to help ensure stronger protection. And finally, there is more than one way to get the flu vaccination, both the traditional shot and an intranasal spray, both of which should be available from their health care provider early this flu season.
P.S. By Dr. Stacy Stryer: Dr. Spitalnick offers some very good information and advice regarding the flu vaccine. While certain high risk groups, such as infants (ages 6 months and up), children with asthma and other chronic diseases, and those who are immunosuppressed are all at a greater risk of developing severe complications if they contract the flu, it is also possible for healthy children to develop complications from the influenza virus. Dr. Spitalnick discussed the best way to prevent children from contracting the flu, which is by receiving the vaccine. There are two forms of influenza protection available, the nasal spray and the traditional injection. The nasal spray, FluMist, may only be given to children ages 2 and older, and is contraindicated for children with asthma, several chronic diseases, and severe egg allergies, yet is more protective than the injection. Good hygiene, such as frequent handwashing and keeping hands away from the face, can also help reduce the risk of contracting the flu.
*Dr. Spitalnik has been a speaker for Glaxo Smith Kline and MedImmune. Dr. Stryer has nothing to disclose.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 20th, 2008 by Dr. Val Jones in Medblogger Shout Outs
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Usually I prepare a weekly (or bi-weekly) feature called “Heard Around The Blogosphere” but this time I’d like to devote my list to images – things SEEN around the medblogosphere. Here’s my top 10 list:
1. Paul Levy’s feet (he is the CEO of Beth Israel/Deaconess Hospital in Boston – and he has some pretty impressive bunions)
2. Doggie scuba gear – I doubt the dogs enjoy it
3. Prosthetic limbs inspired by “retro” furniture – from Medgadget.com
4. TV sunglasses for use at the dentist’s office – now that will keep your mind off things!
5. A fake necktie is actually a cooling device – anesthesiologist Joe found this interesting Japanese invention for men.
6. Beer goggles from the Happy Hospitalist
7. Bizarre bread sculptures that resemble human body parts – from Boing Boing
8. Too many fingers – art by Street Anatomy
9. A skeleton necklace – found by Happy Hospitalist
10. Margarine ad with something lost in translation – Fail BlogThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
