Monday, March 23, 2015

Safety first? Not with my patients!

'Safety first' is a mantra of today's hovering parents.  It's the default explanation that a parent invokes when an edict has been issued that cannot be challenged or reversed.

"Mommy, can I pleeeeeeze have a water pistol?"

"I'm sorry, honey.  You know how Daddy and I feel about guns.  This is a safety issue.  Now go and practice your violin and afterwards help yourself to some kale chips."

Caution! Water Pistol Zone Ahead

The safety concept has crept into the medical arena.  In many cases, safety concerns about our patients are justified.  I see many of our elderly hospitalized patients approaching hospital discharge who face safety concerns at home with respect to falls, understanding complex and new medication lists and monitoring active medical issues.  Hospitals today have a staff of capable and compassionate professionals who do excellent work protecting patients poised for discharge.  This effort saves patients suffering and saves the system cash -  a medical win/win.

It's no victory for a cardiologist to rescue a patient from congestive heart failure if the patient goes home and doesn't take her medicines or veers widely off the recommended diet.

But sometimes safety should not be first.  How safe would you want to be if your quality of life would suffer?  To those who argue that safety is paramount, would you support the following proposals?

  • Outlawing motorcycles
  • Decreasing the speed limit by 10 mph on every road
  • Prohibit high school and college competitive athletics
  • No swimming - anywhere
  • Avoid gluten - the silent killer
Don't take the above too seriously, since I don't.  But, here's my point.  I am often asked to place feeding tubes in elderly individual after they are tested and told that it is not safe for them to take food or drink by mouth.  These patients are found to have imperfect swallowing function. The fear by those who make these recommendations is that the patient will choke while eating with some food dropping into the lungs causing a pneumonia.
These concerns are real, but we need some context.  First, if all 80 year old folks were subjected to the conventional swallowing test, many would be found to have swallowing dysfunction, and yet they are eating and drinking without significant difficulty.  So, we have to be cautious about placing a feeding tube just because a swallowing test is abnormal.  Secondly, many elderly patients have few pleasures remaining in their lives.  Are we comfortable convincing them or their guardians to take food away when this may be a singular pleasure for them?   Even if oral feeding has risks, for many of these folks I suggest that it may be the better choice.   I think that we talk many of them and their families into the tube, which has it's own medical risks in addition to its effect on human dignity and quality of life.

Do feeding tubes make sense for some patients?  Definitely.  But, it shouldn't be for everyone,  We can devise a series of rules to live by that would make us much safer than we are now.  Would you want to live like that?

Sunday, March 15, 2015

Futuristic Medicine

I just deposited a check into my bank account by photographing the check with my iPhone and zapping it through cyberspace.  I realize this is a yawn to the under 35 crowd.  Soon, there won’t be any paper checks as the entire transaction will occur electronically.  As a member of the over 35 crowd (plus 20 years), I am wowed by this process.  I remember being astonished when my kids told me how they performed this same process a year ago.   It’s the same amazement I experienced when I first read about a new piece of technology called a ‘fax machine’.

"You mean you slide a document into a machine and an exact copy emerges elsewhere?"

In my younger days, depositing a check into a bank account meant waiting in line with my bank book in hand waiting for a living, breathing human to count and record my allowance and snow shoveling earnings.   The bank that my kids use today has no physical offices.  It is entirely in the Twilight Zone.

Medicine will not be left behind here.  The manner in which medical care will be administered will be beyond what we can imagine.  We are seeing glimpses of it already, but our vision of its trajectory is limited.  There will be huge advances, but as with all technology, there will be a cost.  The traditional doctor-patient relationship will fade out and will no longer be the bedrock of medical care.  There will be nostalgia for it from those who experienced it, much as I have warm memories of bank books, rotary phones, ice cream sodas and playing basketball after school in the school yard.

Find this phone in the Twilight Zone

I’m sure there is technomedicine going on today that I’m not aware of and would amazed me.  Smart phones and their derivatives will become medical routine diagnostic tools.

Easy stuff

  • Tell Siri your history and send a photo of your rash to DERM APP and prescription will arrive at your door in 1 hour.
  • Place phone on your chest and cardiopulmonary data will be forwarded to your cardiologist who will transmit medication adjustments to you electronically.
  • Shine beam of light through a urine specimen which will confirm if urinary tract infection present.
Hard stuff

  • Coronary bypass surgery performed robotically by a surgeon in New York City on a patient in Abu Dhabi.
  • Artificial organs created in 3-D printers.
  • Miniature cameras journeying through the digestive tract, circulatory system and major organs delivering customized treatment for various diseases.
  • Smart phone analysis of saliva sample which will screen for risk factors for 20 common chronic diseases that will have effective preventive strategies.
  • Satellite delivery of yet to be discovered form of radiation to the developing world which will decimate food borne illness.
  • Patient will place his palm on a glass and an electronic signal will be transmitted to internal organs whose function needs adjustment to treat disease or preserve health.
I still use a stethoscope.  It's not a collector's item yet, but I don't think it will be much longer. 

Sunday, March 8, 2015

Musings and Memories from Manila

I have a good memory, which has often been a great asset for me. Medical school in the 1980’s required massive memorization of arcane facts, formulas and anatomical structures. The philosophy then was that it was better to spend hours memorizing stuff every night then it would be to simply look them up when the information is needed.  My tone here conveys my view of this approach.

I can remember the phone number in the house I lived in until I was 8 years old.  Impressive? Perhaps.Useful? I doubt it.

Some folks have long memories, which is not always a gift.  There are events and painful moments that while they will always be stitched within our personal tapestries, they may be better placed beyond easy reach.

Nations also have long memories.  I am writing now from Manila on the other side of the globe. Yesterday, I was snorkeling and witnessed a shipwrecked Japanese warship sunk in WW II by the Americans.  The war in the Pacific theater between the Japanese and the Americans was brutal and protracted.  The Philippines was one of the the staging grounds of this contest, and they bore an enormous cost of collateral damage.  I asked a Filipino citizen, the manager of our hotel in Coron, if Filipinos had any residual anger against the Japanese.  He said no, as enough time had passed to heal the wounds inflicted in the middle of the last century.

Was this the truth or merely a sanitized answer for an American tourist?  On this very morning, I read that President Park of South Korea again asked the Japanese government to assume deeper responsibility over the Korean ‘comfort women’ that Japanese soldiers coerced and abused during the Second World War. South Korean hasn’t quite forgotten.

In Manila, there is a cemetery of just Americans who died in the Philippines.  It’s a vast field of crosses, and an occasional Star of David, that stretches beyond view.  I doubt that their families have forgotten.

Manila American Cemetery and Memorial

Later today, I fly to Tokyo, the capital of a country that started a war against us, killed many thousands of our men and committed atrocities.  Of course, the Japanese have their own narrative, which they regard as legitimate.  They have a memory of atomic weapons that no other nation can share.  I am traveling to Japan with excitement and enthusiasm. It's a new century now.  Time does dull our collective memory.  People and nations can change.

I’m still figuring out what’s really worth remembering.  An old phone number or the names of the body’s tiny bones and muscles do not seem like memories I need to hold on to.

If I were able to clean out my cerebral crevices of of all those faded facts and dusty data, I wonder how much room there would be for stuff that really matters.  The first to go should be that rotary dial phone number from 50 years ago.  (201) 731-7561 begone!

Sunday, March 1, 2015

Whistleblower Abroad!

This is a Whistleblower Holiday.  A few weeks before this posting, we are setting off to the Philippines.  After about 10 days there, we're off to Japan, where we expect to savor the full potential of sushi and other delicacies.  This will be the biggest trip of my life.

I leave with enhanced immunity having received the influenza vaccine, a belated tetanus booster and the oral typhoid vaccine - veritable germ armor!

No Traveler's Diarrhea!

Why the Philippines?  My daughter, Elana, is spending a year there teaching at an international school.  We are going because she is there.We all know the advantage of maintaining low expectations.  Here are some of mine.

  • Pull an all-nighter the night before departure to reduce the expected jet lag.  Manila is 13 hours ahead of Cleveland time.
  • Don't miss the initial 7 a.m. flight out of Cleveland.
  • No one on any of the 3 flights sitting in front of me reclines.
  • The airport WiFi actually works.
  • Our circulatory systems do not form blood clots during our 24 hours of flying time.
  • The family with the crying baby is not on our flight.
  • My iPad and cash will not be separated from their owner.
  • My box of imodium won't be opened.
  • The malaria prophylaxis pills work.
  • The jet lag upon our return will resolve in a month.
Timing is everything.  Today, the temperature in Cleveland approaches minus 30 with the windchill factor.  It's 78 degrees in Manila now.  Looking forward to feeling the warmth of the sun and the daughter.

Sunday, February 22, 2015

Measles Vaccine - A Right to Refuse Treatment

It’s been amusing to watch Rand Paul, a doctor, trying to ‘clarify’ comments he made suggesting that vaccines for kids should be a matter of parental choice.  Conversely, Rick Perry some years ago had to walk back his aggressive pro-vaccine stance, when he championed mandating HPV vaccines for young girls.  This political clumsiness is not restricted to the GOP.  In 2008, both Barack Obama and Hillary Clinton argued that 'more research was needed on vaccines' potential side effects'. Presidential candidates, it seems, have not all been vaccinated against Panderitis.  

Of course, I recognize an informed individual’s right to refuse treatment.  An adult with appendicitis has a right to refuse appendectomy, against the advice of the surgeon. 

"You mean I didn't have to get sick?"

Does a parent have a right to deny the measles vaccine for their kids?  I don’t think so.  Here’s why.
  • Medical evidence provides overwhelming support for the vaccine’s safety and efficacy.
  • Unvaccinated children pose a health risk to other school children.
  • The claim that any vaccine causes autism has been vigorously refuted.
  • Adults do not have an absolute right to deny children medical care.
I doubt that a 15 month old child can make an informed choice about the measles vaccine.  Would those infants who have been denied the vaccine, support this decision when they reach the age of understanding?

Parents have rights also.  They have the right and the responsibility to make health decisions for their kids.  This right, like all rights, is not inviolable.  Parents should not be able to deny a life-saving blood transfusion or curative chemotherapy to a minor child who does not have the capacity to understand the ramifications of a denial of care.  In contrast, some kids should be permitted to make their own decisions even if they have not reached the age of majority.  A 17 year old Jehovah’s Witness, for example, has a more legitimate argument in turning down a blood transfusion than would a 5 year old. 

Immunizations are a towering achievement of the medical profession that has saved millions of lives.  No, they are not perfect, but they work much better than nearly every medical treatment that doctors prescribe.  Moreover, vaccinating kids offers a public health benefit that extends far beyond the youngster who is vaccinated. 

If you are a libertarian who is suspicious of government, then go make a sign and protest.  This is your right.  But, vaccinate your kids.  They have a right to good health.  And, so do the rest of us.

Sunday, February 15, 2015

Is Your Doctor 'Aware'?

Every doctor understands what the phrase, doctor aware’, means.  This is the phrase that hospital nurses record in their nurses notes when they have notified the doctor, usually by phone, on a patient’s issue.   Once the ‘doctor is aware’, the nurse is in the clear and has transferred responsibility for the issue to the physician.
Here are some samples of doctor awareness.

Phone Call Notification                                           Nursing Record

Doctor, Mrs. Leadbelly just vomited.                       Doctor aware!
Doctor, Mr. Wobbly is dizzy.                                        Doctor aware!
Doctor, the ultrasound showed a gallstone.         Doctor aware!
Doctor, Mrs. Hothead has a fever.                             Doctor aware!

Physicians often roll our eyes over these conversations.  Some of these notifications are communicated in the middle of the night about patients we do not know.   Although we can’t usually address the abnormal finding directly at that time, nor do we often need to, once we have been made ‘aware’, the responsibility of the entire case is now ours.   For example, if we are awakened by a nurse asking if she can give antacids to quell a patient’s heartburn, we are likely to agree with this seemingly reasonable recommendation. The chart will record that we are ‘aware’.  If that ‘heartburn’ turns out to be a harbinger of a more serious condition, then the physician will be liable for his action.

If  it's more than heartburn, will we end up in the dock?
Before you pounce on this doctor accusing him of haste and sloppiness, keep in mind that we handle hundreds of these calls every year.  If we were to run to the hospital on every one of these calls to see the patients personally, we’d have to live in the hospital like a medical intern. 

A standing joke between physicians and nurses is after a nurse reports an abnormality to the doctor, the physician wryly responds, ‘I am not aware!’

One particular vexing example of this is when a nurse calls me at 8 pm as the attending physician wants me to approve that the patient can be discharged home.   Often, one of my partners has seen this hospitalized patient during daylight hours.  As I have no knowledge of the particular patient, I am reluctant to sign off on the after-hours hospital discharge, which would force me to accept enormous responsibility on the appropriateness of sending the patient home.  In the most recent example of this, I told the nurse that I cannot clear the patient as I was not involved in the case.  The attending physician must make his own independent decision if his patient can be sent home.  Of course, the attending doctor who is asking me to approve hospital discharge is engaging in the same ‘Dr.Aware’ procedure at the physician level.   Familiar with the concept of CYA?

We do the same thing with our patients.   When patients reject our medical advice, guess what phrase we enter into the record.

Sunday, February 8, 2015

FDA and Herbal Medicine - Caveat Emptor!

Many of my patients are taking herbal supplements, or so they think.  This herbal and health supplements industry likely is envied by traditional pharmaceutical companies.  The latter has to spend zillions of dollars proving safety and efficacy to the Food and Drug Administration (FDA).  Many of these drugs are cast aside during the approval process or afterwards when serious side effects become known or a new medicine is proved safer and superior.  While it’s not quite a crapshoot, there is a strong element of chance at play here.

Roll the Dice with the FDA?

Herbs and the supplements that are saturating our airwaves escape FDA scrutiny.  They will only draw governmental fire if they are deemed to be dangerous.  They are required to use certain language in their promotional materials that differs from traditional FDA approved prescription medicines.  Take a look at this example:

Fosamax:  The FDA has approved this for the treatment and prevention of osteoporosis
Glucosamine chondroitin:  Promotes bone health

Somehow the vague but promising phrase, ‘promotes bone health’ is supposed to insulate the company from a claim that it is approved to treat an actual disease.  However, for most of us, promoting bone health sounds like it’s designed to prevent osteoporosis, which is exactly the intent of the company’s marketing folks.  The language may be legally distinct from the Fosomax verbiage, but it sure sounds the same to me.

The FDA has a very light regulatory hand over dietary supplements making sure that there are no overtly misleading claims and that the product contains what the label states it is.  There is no FDA approval of efficacy as is required for prescription pharmaceuticals.

With a market worth billions of dollars, would you prefer to invest in a pharmaceutical company that might need 7 years to bring a drug to market or in a supplement manufacturer that only needs to cross over a few speed bumps before marketing potions that combat fatigue, joint pain, depression and memory lapses?

It amazes me that the public swallows millions of these pills in the absence of medical evidence of efficacy.   Who says that Americans are not a people of faith?

Recently, a New York State investigation discovered that 4 out of 5 herbal products tested contained none of the herbs listed.  The investigation examined herbal products at some little known ‘mom & pop’ pill shops including Walmart, GNC, Target and Walgreens.

If a company is peddling a placebo, can't it at least accurately label the herb?  If I'm buying a jar of snake oil to ease my rheumatism, or should I say to promote good joint health, then I expect that the useless elixir won't be lizard oil, olive oil or motor oil.  

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