A patient was admitted to the hospital with chest pain and underwent a cardiac catheterization, The patient was found to have a partly blocked coronary artery that was opened with balloon angioplasty and stenting. The patient was started on aspirin and clopidogrel (Plavix) and discharged to home. The day after the discharge the patient returned to the hospital with recurrent chest pain and on repeat catherterization it was found that the stented artery had partly occluded with clotted blood and needed to be cleared.

Clotting or thrombosis within the stented part of the artery is an uncommon complication and can occur anytime following the procedure for up to a year or more. Within the first 30 days the most common cause of clotting is noncompliance with antiplatelet medication, i.e. the patient stops taking their clopidogrel.

In this case the patient was appropriately treated and discharged from the first admission after being given a prescription for clopidogrel. The patient then sued the cardiologist because . . (wait for it) . . he claims that he was NEVER TOLD TO FILL THE PRESCRIPTION AT THE TIME HE WAS DISCHARGED thus leading to the clotting. Never mind that:

1. Once-a-day medications like clopidogrel are usually given the same day as the discharge and that the antiplatelet effect lasts up to 3-6 days.
2. There is still a small chance of clotting despite treatment with clopidogrel.
3. A patient who does not follow simple directions for a scheduled once-a-day medication is either incompetent (thus requiring a guardian) or themselves negligent.

But despite the obvious frivolous nature of this lawsuit, our current system allows it to progress all the way to trial despite the low possibility of success all because a jury of individuals picked specifically for their ignorance of modern medical practice might find in favor of the plaintiff. As usual, a huge waste of time and money for all those involved.

A metanalysis of 5 random controlled studies has found that chewing gum in the immediate postoperative period significantly shortens the length of time for the resolution of ileus by about 1/4 to 1/3 than non-gum chewing control patients. Additionally, the gum chewers were almost 20% more likely to be discharged from the hospital earlier than non-chewers without any statistical difference in complications between the two groups.

This is entirely plausible. The act of chewing normally stimulates the alimentary tract (the continuous tube from mouth to anus) to prepare it for food breakdown and digestion. It appears that chewing gum is a safe and effective (and cheap) way to shorten the recovery time after colorectal surgery.

Chewing gum also is a good way to equalize the pressure differential between the inner and outer ear during assent and decent in pressurized aircraft. But this is off topic.

I was called by a local ER physician for a possible admission. The patient was elderly and by elderly I mean that she was entering her child bearing years when the US was entering World War I. She had been brought by her family to the ER because of chest pain which had since resolved. The ER physician revealed that the family and patient only wanted medical options (like pain relief) and did not want any invasive procedures. Both the ER physician and I agreed with this considering the patient’s advanced age, any invasive/intensive treatment attempts would likely cause more harm than good. The first rule is “Do no harm”. Right?

The patient’s EKG was normal. Her first set of cardiac enzymes were all normal. She had no further chest pain or any other symptoms and she didn’t want to be resuscitated in the event that she had cardiopulmonary arrest (DNR). Satisfied, I didn’t seen anything more that we should do and I recommended discharging the patient home on nitrates, aspirin, clopidogrel, and pain medications, and have her follow up in the office within a few days. Then the ER physician threw me a curve ball.

ER Doc: “I was going to admit her to telemetry for observation”.

Me: “To observe for what? We aren’t going to do anything more than we are doing now.”

ER Doc: “Well, to rule her out. Make sure she didn’t have a heart attack.”

Me: “But even if she has had a heart attack it won’t change our treatment! We’re not going to do a cardiac catheterization or cardiac bypass on her. She won’t agree to it and her risk of dying from those procedures alone would be unacceptably high.”

ER Doc: “What if she has more chest pain?”

Me: “Then she can take her home medication or come back to the ER for treatment in the event that she has severe refractory pain. She might have more chest pain tonight. She might have severe chest pain 2 weeks from now. I can’t admit a patient just for convenience!”

ER Doc: “But we’ve only gotten one set of cardiac enzymes on her. We need to get at least one more set to make sure that she didn’t have a heart attack.”

Me: “Does she want to consider invasive testing or treatment if her enzyme levels are elevated?”

ER Doc: “No, the family and the patient just want medical treatment regardless.”

Me: “Is the family or the patient insisting on being admitted to the hospital?”

ER Doc: “No, they are fine with whatever we recommend.”

Me: *Banging my head on the table* “All right. It’s been several hours since her chest pain resolved and several since her first cardiac enzyme levels were drawn. You can get a second set now and if this set is normal then you can send her home.”

The ER physician agreed to this, the second set of cardiac enzymes were normal, and the patient went home.

The practice of emergency medicine (among other high risk specialties) has become so regimented and infused with defensive medicine tactics that many ER docs are not even aware of how this has changed the way they think. It seemed as if this ER physician could not fathom the concept that we would send home a patient who could easily have just had a heart attack despite the fact that we were going to do absolutely nothing different for her then if she went home. Even though the possibility of litigation in this case was remote it was the constant and overall threat of litigation that has fundamentally changed the thinking of physicians and how they practice medicine.

This change in thinking has had significant consequences. Ever wonder why we spend so much on medical care? Part of the answer lies in this example. This ER doc was about to turn an $800 ER visit into a $4,000 hospital admission. Now imagine this happening all over the country in multiple variations and degrees of absurdity tens of thousands of times EVERY DAY.

Medical malpractice attorneys are not directly at fault for this mess. But I don’t see this problem correcting itself as long as physicians feel that the current tort system is a disincentive to changing from a mostly CYA (Cover Your Ass) system to one which couples good medical care to proper resource utilization. However, tort lawyers tend to oppose every single reform attempt and so in my book, if they are not part of the solution, then they are part of the problem.

The patient is in his 50s and is suffering from a neurological disorder that has impaired his ability to breathe and swallow. He is dependent upon a feeding tube inserted into his stomach for nutrition and a ventilator inserted through a tracheostomy to breathe. He faces the prospect of being like this for the rest of his life.

The tracheostomy prevents him from speaking but he is otherwise completely awake and alert and is able to communicate by writing. He understands his diagnosis and prognosis.

The patient has some ability to breathe on his own and so the pulmonology service was trying to see if the patient could recover enough strength to come off the ventilator (weaning). Indeed, his pulmonary status gradually improved to the point that he was able to come off of the ventilator for short periods (breathing only from an oxygen mask placed over the tracheostomy tube).

Unfortunately he would eventually get fatigued and need to be placed back on the ventilator. It was during one of these trial periods that the patient refused to go back on the ventilator. He made it very clear (via writing) that he understood that he might die without the ventilator but that he didn’t want to live if he was going to be dependent on the ventilator for the rest of his life.

This was witnessed by the family, the nursing staff, and myself and was well documented. But the pulmonologists felt that the patient may not be capable of making his own decisions because the carbon dioxide level in his blood was rising as a result of his ventilatory failure. However, it was obvious that he remained clear headed and able to determine his own fate.

Then one of the lung specialists ordered that the patient be sedated and placed back on the ventilator. Hold on a sec! Isn’t that assault? Yes it is. But the specialists felt that from a liability standpoint, they could not be 100% sure that the patient is fully competent since he could not speak and he had a relatively high carbon dioxide blood level. They felt that this uncertainty could be brought up in court and used against them should the case ever go to trial.

Wait a minute! The family witnessed the patient communicating with the staff and they agree that he is competent and free to make his own decisions. All of this has been witnessed and properly documented. And nobody is talking about a lawsuit. As far as I know there are no issues of potential malpractice in this case. But the specialists felt that they should err on the side of keeping the patient alive since some uncertainty remains.

Sadly, the specialists are right. Not ethically right. They are legally right. They are playing the odds. Far fewer lawsuits are filed for similar cases where the patient is kept alive against their wishes then in cases where the patient died because a certain treatment was not given. There is also the practical aspect that time can be taken to make absolutely sure that the patient is competent, informed, and their wishes clearly known before treatment is withheld.

The downside of waiting to make absolutely sure of what the patient wants (or allow time for the patient to change his or her mind) is that this may prolong suffering before the patient ultimately is allowed to die. But this is what the patient wanted to avoid in the first place!

“Some molds are toxins, and exposure to these toxins may hypoactivate parts of the brain that deal with emotions.”

That’s not much of a theory. I have no doubt that people who live in damp, moldy houses tend to feel more depressed. What I can’t figure out is how these researchers came to the conclusion that an environmental toxin is the causal agent when the elephant in the room is the poor living conditions.

People who are aware that they have mold problems know this because they can see the mold stains and the chronically damp conditions. If they can see mold stains then likely they don’t have the financial means to remove the mold and repair the leaks causing the chronic dampness. So they are likely to be of lower socioeconomic status and there are plenty of studies linking lower socioeconomic status to greater rates of depression.

There is far less if any definitive data that links environmental toxins (from mold or otherwise) to higher rates of depression. There is not even a plausible neuro-chemical model on how environmental toxins could cause mood disorders.

The data used from the study came from a survey where the participants themselves rated how damp and moldy their living conditions were. A better controlled study would be something like this; house several volunteers in nearly identical conditions (apparently moldy and damp rooms) but in half the rooms the “mold” would either be nontoxic paint or a nontoxic mold species while the other half would have the usual “black mold” (asthmatics would be excluded). Then evaluate each group for depressive symptoms. If you want to evaluate a single variable as a cause of something then it’s important to eliminate as many other variables as possible.

I do believe in something called “black mold” hysteria in which people believe that these common household mold species are causing all kinds of somatic ailments (only links with asthma and certain other pulmonary allergic conditions have been proven). Now we can add depression to this growing list.

The problem is that the WHO ranking has very little to do with the quality of health care as implied by ‘Sicko’ and by many liberals. Of several variables, only life expectancy is used as a measure of health care quality. But this is a bad measure of overall health care quality and does not correlate exactly with health care spending. This is due to the fact that there are multiple other variables other than health care that directly impact life expectancy.

For example, obesity alone is calculated to decrease US life expectancy by 0.3 to 0.75 years and the US has the highest rates of obesity in the world. Notice that Japan has one of the lowest rates of obesity and is among the countries with the highest life expectancies. The WHO report acknowledges that other variables like higher HIV rates, higher tobacco abuse rates, higher rates of risk factors for coronary artery disease (including obesity), and higher rates of homicides in the US compared to other industrialized countries combine to decrease the life expectancy for Americans.

The generally poor life style choices of Americans are more likely to have a causative effect on health care spending than the other way around. I.e. more health care spending is needed to take care of the conditions like heart disease that result from our poor health habits. This is more logical than to assume that high health care spending has anything to do with rates of obesity or smoking.

The other measures have to do with how these health systems are funded, distributed, and how responsive they are to the health needs of the population. Of these, the one that correlates the closest with health care spending is responsiveness. This is because this measure is very closely tied to the availability of health care resources and countries that spend a lot on health care have plenty of resources. The US ranks #1 in responsiveness. The US ranks only #54-55 in something the WHO calls the “fairness of financial contribution” which is the liberal way of saying “it’s only fair that your health care is paid for by someone else”.

Even though the US is #1 in health care responsiveness (which translates into shorter wait times, greater access, more innovation, etc) this one measure is overshadowed by the fact that the WHO believes that equal health care distribution and financing has just as much if not more weight in its rankings. This is what leads to the strange juxtaposition of the US health system being ranked only two spots above Cuba’s. Of course everyone knows that Cuba has a pretty good health care system . . . . for 1959 (I hear they have some nice classic autos too).

The WHO rankings have more to do with what liberals value in a health care system (fairness, equality, etc.) than what most Americans value in a health care system (quality, access, efficiency, innovation, convenience). Though this doesn’t stop people like Mr. Moore from trying to convince everyone that these apples are really oranges.

When you take your car in to the mechanic to have the engine worked on and they screw up your transmission, you don’t expect to have to pay for their mistake. This is the logic that the Federal government is using in its new regulations for hospital reimbursement. CMS will no longer reimburse hospitals for the costs of treating eight complications it considers to be completely preventable. The first 3 should be 100% preventable;

1. Objects left in a patient during surgery (about 1500 cases each year out of millions of procedures performed in the US).

2. Blood incompatibility (less than 40 deaths per year out of millions of units of blood transfused).

3. Air embolism: Air getting directly into the blood during procedures creating bubbles that can cause severe organ damage and death.

The other complications though avoidable in theory are very difficult to prevent 100% in practice.

4. Mediastinitis: Infection of the middle part of the chest usually from contamination during surgery. However there are many other causative variables that are not fully under the control of the surgical team to prevent i.e. blood infection from another site that spreads to the mediastinum and post operative wound infection from coughing or respitory distress.

Studies have found several risk factors for mediastinitis including morbid obesity, diabetics on insulin, surgery lasting more than 5 hours, and a post operative stay in the ICU more than 3 days. So the question becomes, are physicians and/or hospitals going to start avoiding chest surgery in patients who are at high risk for mediastinitis? Will this lead to excessive use of peri-operative “prophylactic” antibiotics which will add to the multidrug resistant bacteria problem?

5. Falls: Anyone who cares for an ailing or elderly family member at home knows how hard it is to keep them 100% safe 100% of the time, even if they are bed bound. Most US hospitals have nurse to patient ratios of 1:5 to 1:8 or more and even with such things like bed alarms and call bells some patients (esp. those with dementia) have the bad habit of getting out of bed without telling anyone. I worry that hospitals may start using more physical and chemical restraints (sedatives) to keep at-risk patients in bed and this can lead to other complications.

6. Catheter related urinary tract infections: The longer a catheter remains in the bladder the higher the risk of infection but even with good care 3-10% of catheterized patients get significant numbers of bacteria in the urine each day and 10-25% of these develop symptomatic infections. Though unnecessary and prolonged catheterization should be avoided, there are cases where it’s absolutely needed like patients with urinary outlet obstruction or neurogenic bladder. Without a catheter these patients risk getting a severe infection or kidney failure by not being able to normally empty the bladder. And again I worry that more patients may be given prophylactic antibiotics even though there is no evidence that this prevents catheter related urinary infections in non-surgical patients.

7. Central venus access catheter related blood infections: Here too, the longer the catheter remains in the higher the risk of infection. Good preventative care does have a significant impact on decreasing these infections. However, the catheter should only be changed to a new site if infection is suspected. Regular changing of the catheter over a guide wire increases the infection risk and regular changing of the catheter to a new site increases the risk of complications like bleeding or pneumothorax.

8. Pressure ulcers: This is mostly preventable as well but not 100% preventable or automatically the result of poor care. Patients at high risk for these ulcers (spinal cord injury with paralysis, advanced dementia, frequent incontinence of urine or stool, poor nutrition, or poor circulation) can develop an ulcer extremely easily. This is best exemplified by the sad case of actor Christopher Reeve who died from an infected pressure ulcer despite getting very good care. These days wound care teams roam most hospitals looking for any early skin breakdown or the beginnings of an ulcer.

_______________________

Despite what the Federal government thinks, complications # 4-8 are not 100% avoidable. It would make more sense for CMS to establish a maximum number of these types of complications per year per hospital based on the number of these cases one would expect to see using the best preventative measures. Then they can penalize hospitals that exceed the maximum.

Otherwise it’s not improbable that some hospitals and physicians may take steps to avoid having to treat patients who are at high risk for these complications. Never under estimate the law of unintended consequences (or the ability of hospitals like any business to try and save money).

Yet it’s surprising how often we forget about this observer effect when it comes to such measurements like surveys. For example, surveys about sexual behavior in western society routinely find that men report having several more lifetime sexual partners than women. Well, duh! Everybody knows this. These results fit perfectly with how we think of gender differences i.e. men as being more sexually aggressive and adventurous and women tending to be more pure and sexually innocent. The problem is that mathematically these results are impossible.

Simply put, if women in a given population had an average of X number of sexual partners and men in the same population had an average of X + Y number of sexual partners then the mathematical question is . . where did this Y number come from? The average number of sexual partners in a given population should be statistically the same! There are many possible explanations;

1. The results are skewed by a few massively promiscuous women (like prostitutes or spring breakers) who were not part of the survey. However, this would mean that the vast majority of those extra “Y” numbers are from visits to prostitutes and Daytona Beach and this is highly unlikely.

2. The results are skewed by men going outside the study population (to other countries) to have extra sexual partners. have you been on a sex tour of southeast Asia lately? Again this is highly unlikely.

3. A significant number of men in these surveys are closet homosexuals who lied about their sexual orientation but included their gay partners in the survey tally. Yea, right. Be gay. Be proud! Unlikely.

4. A majority of men surveyed actually believe that they have had more sexual partners then they really did. This one is plausible for a certain number of men who are legends in their own mind but not for the vast majority. Unlikely.

5. Filling out the survey in the presence of an interviewer changed the behavior of those surveyed causing men to tend to inflate the number of their sexual partners while women tended to deflate the number. Ah, the “observer effect”. The 1999 US government study was conducted by “detailed, in-person home interviews” and obviously this changed the results.

This study says more about how people answer personally sensitive questions in the presence of an interviewer than it does about the reality of their sexual behavior. It also says a lot about what is perceived as socially expected and acceptable as far as differences in sexual behavior between men and women. In the presence of an official government researcher, study participants tended to answer with what they believed was acceptable and/or expected, i.e. that men should have more sexual partners and that women should have fewer.

The reality is likely that men have fewer sexual partners than we expect and women have more and Americans probably still have a very inaccurate and incomplete picture of our sexual behavior because we still rely on this survey method in order to gather data.

From Mr. and Mrs. Smith;

John Smith (Brad Pitt): “How many? Ok… I’ll go first, then. I don’t keep exact count, but I’d say, uh, high 50s, low 60s. I mean, I know I’ve been around the block an all, but… ”
Jane Smith (Angelina Jolie): “312.”
John Smith: “What? How?”
Jane Smith: “Some were two at a time.”