September 18th, 2008 by Dr. Val Jones in Celebrity Interviews
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Methacillin resistant staphlococcus aureus (MRSA) is a deadly bacterium that is becoming more and more common inside and outside the hospital setting. No one is immune, not even babies like this one who died from an unknown exposure.
Seven-time NBA All-Star Grant Hill has also experienced the ravages of MRSA. I interviewed him about his near-death experience.
Dr. Val: Tell me about your recent experience with a severe staph infection.
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August 16th, 2008 by Dr. Val Jones in Health Policy
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No one wants to become infected during their hospital stay. Unfortunately it’s not possible to guarantee that it won’t happen. Bacteria are everywhere. We carry them on our skin, in our bodies (especially our digestive tract), and they live in food, clothing, and anything we touch. When we undergo surgery, we cut through the skin/blood barrier that keep the bacteria out, making us vulnerable to inadvertent invasion.
There are ways to reduce the risk of infection (sterile surgical technique, appropriate wound care, and personal hygiene) but the risk is not zero. For the risk to be zero, one would have to begin with a “sterile” patient – a patient who carries no bacteria on or in their body. Since that will never happen, I’m afraid that hospital acquired infections are here to stay.
However, with government-sponsored health insurance programs on the brink of bankruptcy, decreasing expenditures is a high priority. Therefore, Medicare is suggesting that there are certain events that should never happen in the hospital and that they will no longer compensate hospitals for care associated with these events. Although I certainly agree that operating on the wrong body part is appropriately classified as a “never event,” the list has become so long that it includes things that cannot possibly be prevented in all cases (things like catching a cold, developing a blood clot, falling, or becoming infected).
What will result from listing infections as a “never event?” Will it encourage hospitals to improve their infection control processes? Maybe. But here’s what I imagine is more likely to happen:
1. More prophylactic antibiotics will be given to patients to reduce the risk of infection, resulting in higher rates of serious drug reactions. Stronger medicine (with broader coverage) will be preferentially selected – further encouraging the development of drug resistant strains of bacteria.
2. Patients who become infected will be transferred to another facility as quickly as possible. The accepting facility will be compensated for the care of the patient since the “never event” didn’t happen at their hospital. Transferring care in the middle of a serious illness increases the risk for other complications, including miscommunications and medication errors.
3. Since Medicare has set the expectation that hospital acquired infections are 100% preventable, anyone who contracts one will be able to sue the hospital. This will deplete the hospitals of their thin operating margins, causing them to cut programs – probably first for the poor and underserved.
4. Additional testing may be done for any surgical admission – nasal swabs (and potentially rectal swabs or urethral swabs) will be used to document the fact that the patient arrived at the hospital colonized by certain bacteria and therefore did not contract a new infection during their hospital stay.
5. Convoluted documentation methods will abound, so that any patient who becomes infected will receive antibiotics for “prophylaxis” and his fevers will be explained as the usual “post-op” central fevers. All staff will be encouraged to carefully document that the patient is being treated prophylactically only, and does not have an infection. In fact, it’s possible that blood cultures will not be drawn so that there will be no documentation of sepsis. Patients who really do have serious infections will receive appropriate care very late (since the first few days will be spent trying to manage the infection without documenting it or identifying the organism). This could paradoxically result in higher death rates.
6. Patients at higher risk for infection (such as those who are immunocompromised – see my research study on risk factors for line infections here) may be passed over for surgical procedures. This risk aversion could negatively impact health outcomes for vulnerable populations (such as cancer patients or HIV+ individuals).
I could go on theorizing, but you get the picture. In my opinion, the “never events” strategy is fatally flawed and will result in excessive litigation, ping-ponging of patient care, over-use of antibiotics, increases in adverse drug events, a rise in multi-drug resistant bacteria, and further reduction of services to the poor. A more reasonable approach would have been to document infection rates at the most hygienic facilities, and offer incentives for others to strive for similar rates.
The “never events” strategy is destined to do more harm than good for patients with hospital acquired infections, though the medical malpractice attorneys may enjoy a new income stream. This is just one more reason why we should never say never.
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See Buckeye Surgeon’s take on this topic and his coverage of Jerome Groopman’s article for the New Yorker on the rise of drug resistant “super bugs.”
See Dr. Rich’s take on never events here.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 12th, 2008 by Dr. Val Jones in True Stories
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Always do right. This will gratify some people and astonish the rest.
–Mark Twain
I am out of town for the week and will be blogging sporadically. I hope you enjoy this true story/repost:
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I remember a case where a young internal medicine intern was taking care of a 42 year old mother of 3. The mother had HIV/AIDS and had come to the hospital to have her PEG tube repositioned. Somewhere along the way, she required a central line placement, and as a result ended up with a pretty severe line infection. The woman’s condition was rapidly deteriorating on the medicine inpatient service, and the intern taking care of her called the ICU fellow to evaluate her for admission to the intensive care unit.
The fellow examined the patient and explained to the intern that the woman had “end stage AIDS” and that excessive intensive care management would be a futile endeavor, and that the ICU beds must be reserved for other patients.
“But she was fine when she came to us, the line we put in caused her downward spiral – she’s not necessarily ‘end stage,’” protested the intern.
The fellow wouldn’t budge, and so the intern was left to manage the patient – now with a resting heart rate of 170 and dropping blood pressure. The intern stayed up all night, aggressively hydrating the woman and administering IV antibiotics with the nursing staff.
The next day the intern called the ICU fellow again, explaining that the patient was getting worse. The ICU fellow responded that he’d already seen the patient and that his decision still stands. The intern called her senior resident, who told her that there was nothing he could do if the ICU fellow didn’t want to admit the patient.
The intern went back to the patient’s room and held her cold, cachectic hand. “How are you feeling?” she asked nervously.
The frail woman turned her head to the intern and whispered simply, “I am so scared.”
The intern decided to call the hospital’s ethics committee to explain the case and ask if it really was appropriate to prevent a young mother from being admitted to the ICU if she had been in reasonable health until her recent admission. The president of the ethics committee reviewed the case immediately, and called the ICU fellow’s attending and required him to admit the patient. Soon thereafter, the patient was wheeled into the ICU, where she was treated aggressively for sepsis and heart failure.
The next day during ICU rounds the attending physician asked for the name of the intern who had insisted on the admission. After hearing the name, he simply replied with a wry smile, “remind me never to f [mess] with her.”
The patient survived the infection and spent Mother’s Day with her children several weeks later.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 12th, 2008 by Dr. Val Jones in Opinion
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I’ve written about raw milk before, but here again we find it making front page news. There has been a recent FDA raw milk crack down in California, and I believe that’s a good thing for public health reasons. Although raw milk enthusiasts ascribe mystical powers to the product (some say its natural microbial flora can cure everything from asthma to autism), I don’t see anything mystical about the pathogens that can grow in room temperature milk: e. coli, salmonella, listeria and even tuberculosis. If you like the taste of raw milk and don’t mind the risks associated with imbibing warm body fluids of manure-encrusted bovines… then go right ahead. But please, don’t put your children at risk.
The New York Times exposed the raw milk counter-culture phenomenon last year. Grocery store milk has been heated and packaged in a nearly sterile fashion so that no harmful bacteria are in it. Farmers collect raw milk from cows, then send it to a processing plant where it’s pasteurized (a heat treatment) and homogenized (blending the creamy part with the skim part) it before packaging the milk for human consumption. This process has virtually eliminated milk borne illness in this country, but now certain farmers are threatening to reverse that progress.
So why are people fascinated with raw milk and seeking out farmers who will sell them milk prior to heat treatment? Raw milk does taste very good, and there’s no doubt that the creamy layer that floats on the top is delicious. In New York City raw milk has a black market, cult following. Should you jump on the bandwagon?
As my regular readers know, I grew up on an organic dairy farm, and had the pleasure of handling cows up close and personal for at least a decade. In fact, their sweet-smelling grass breath, and not so sweet-smelling cow patties are etched permanently in my mind. Cows are curious, somewhat dim witted, and generally oblivious to the terrain upon which they tread.
Cows will stand in manure for hours without a moment’s regret, should you present them with fresh hay to eat or some nice shortfeed. They drop patties on the ground, in their troughs, and occasionally on one other. Their flicking tails often get caked with manure as they swish flies away and they scratch their udders with dirty hooves as well.
This is why when it comes time to milk them, farmers need to wipe their udders carefully with a disinfectant scrub before applying the milk machine. Mastitis (or infection of the udder teets) is not uncommon, and is a reason for ceasing to milk a cow until the infection has cleared.
And so, the cleanliness of raw milk depends upon whether or not the farmer removes all the excrement carefully, scrubs the teets well, and remembers not to milk the cows with mastitits. It also matters whether or not the cows are harboring certain strains of bacteria – which often don’t harm the cow, but cause very serious problems for humans.
Did I drink raw milk as a kid? Occasionally, yes. Were my parents super-careful about the cleanliness of the milk? Yes. Did I ever get sick from raw milk? No. Would I give raw milk to my kids? No.
I appreciate that epicures want to experience the flavor of raw foods, but for me, the risks are simply not worth it when it comes to milk. There is no appreciable nutritional benefit to drinking raw milk (in fact, store bought milk is fortified with Vitamin D, which is critical for healthy bones), and it caries a small risk of serious infection. I agree with the FDA’s ban on interstate sales of unpasteurized milk, and would not want to see raw milk available widely for general consumption. Of course, to get around this ban, some companies are selling raw milk and cheese under the label “pet food.”
It’s a crazy country we live in – anti-bacterial hand wipes, soaps, gels, plastics and an insatiable appetite for raw milk. As a doctor, I throw up my hands. Is raw milk getting a raw deal? Some farmers may feel that way – but this former farmer is pleased to have access to safe, clean milk. What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
Methacillin resistant staphlococcus aureus (MRSA) is a deadly bacterium that is becoming more and more common inside and outside the hospital setting. No one is immune, not even babies like this one who died from an unknown exposure. 
