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Healthcare Updates

Links and commentary to healthcare news around the internet

Healthcare Update — 08-17-2012

Jury … in Florida … awards family of child $28.4 million after defendant physicians reportedly ignored the lumbar puncture results of a “fever wracked” infant and failed to give the infant antibiotics for meningitis. The doctors allegedly “robbed the … youngster of a normal life” since he later had a stroke and will have the mental capacity of an 18 month old for the remainder of his life. Some of the damages will be capped at $1 million while the Florida Supreme Court decides whether the caps on non-economic damages are constitutional As far as I can tell, neither Jim Dwyer nor Jill Abramson had anything to do with writing or publishing this article. As our government prepares to extend “insurance” coverage to tens of millions more people, states such as Maine devise more ways to reduce benefits under that “insurance” and many people find that they can’t afford to purchase their employer’s insurance, but earn too much to obtain subsidies to purchase the “insurance.” WellPoint sucks … if you’re a hospital executive. The insurer, which owns Blue Cross plans in 14 states, was rated last in a poll of 400+ hospital executives for allegedly rejecting legitimate claims and for failing to fix wrongly-denied bills. Cigna was rated highest in the survey. Pictures of the Texas “Whambulance” emerge. I can’t imagine trying to lift someone into the back of this thing. But it would be good if they ever needed to rescue someone from a monster truck show.

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FDA’s Latest Deadly Drug: Codeine

Get ready for more governmental regulation of opioids and maybe even some black box warnings added to the prescribing information for c0deine-containing drugs … just for everyone’s safety, of course. According to this FDA Special Bulletin on Safety Information, three pediatric deaths and one case of respiratory depression were documented in the medical literature after children took codeine-containing compounds. The etiology for the deaths was allegedly because the children had a variation in their cytochrome P450 enzyme that caused the codeine to break down faster into morphine, high levels of which, according to the FDA, “may be fatal.” If your child or your patient is an “ultra-rapid metabolizer” of codeine, he or she could DIE. The FDA also published a “Drug Safety Communication” that disclosed the studies on which its recommendations were based. One case cited by the FDA as “proof” that codeine can kill you involved a 2 year old child with sleep apnea who underwent tonsillectomy and adenoidectomy and who died three days after surgery. At autopsy, the child had elevated levels of codeine and morphine in his system, had aspirated food particles, and also had bilateral pneumonia. No mention of how much codeine the patient’s parents gave the child, only of the dose that was prescribed. No mention of how bilateral pneumonia or aspiration in a young child can be deadly. The researchers concluded that the elevated morphine levels “may” have contributed to the child’s death. The FDA wants you to believe that there was a causal connection there. Another article cited by the FDA was from the same authors who now found three additional cases of children who died after having tonsillectomy/adenoidectomy and were prescribed codeine. I didn’t purchase the article, but I also am assuming that there were no controls for dosing of the medication, only for prescription of the medication. In other words, I doubt that the researchers would be able to tell whether the parents accidentally just gave the child too much medication as opposed to whether some genetic variant caused higher than normal blood levels of the medication at normal doses. I also did a PubMed search for “children codeine p450” and also “pediatric codeine p450“. There was one Canadian case report of a mother who was an “ultra rapid metabolism phenotype” whose breastfed child had fatal opioid intoxication after the mother used codeine. There was another case report from Canada of a 5 year old girl who died from hydrocodone overdose when she was taking both clarithromycin for an ear infection and valproic acid for seizures. The medications decreased metabolism of the drug and she also had a genetic defect that decreased the metabolism of the drug. None of the other articles that I found mentioned pediatric death due to an interaction between opioids and cytochrome P450. Now, based on 4 deaths out of likely hundreds of millions of codeine prescriptions, the FDA is “currently conducting a safety review of codeine” and is recommending that doctors use low doses of codeine for patients in pain or that doctors just use another medication completely for children in pain. The FDA also recommends that caregivers monitor patients for signs of opioid toxicity. These recommendations are already in the prescribing information for Tylenol with Codeine. Oh, and the FDA also notes that doctors can always perform “FDA approved” genetic testing to see if children have the gene responsible for rapid metabolism of codeine. I can’t help wonder what motivation the FDA has to issue this warning about 4 deaths in tens or even hundreds of millions of prescriptions that were hypothesized to have been caused ...

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Tony the Doorman

By BirdStrike M.D. I’m sitting in my apartment on the West Coast starving, listening to my stomach growl, waiting for my pizza to be delivered.  It is taking unacceptably long.   I’m going back and forth on how little I can tip the pizza delivery man without feeling too guilty to actually enjoy the pizza if and when it ever arrives.  There’s a knock on the door.  Thank God, I think to myself, it’s about time. I open the door, “Pizza’s here,” says the pizza man.  “You’re the best doctor in the world!” “What?” I say.  “Yeah, the doorman says you RULE!  He said if I ever need to get checked out, to go see you.  He says, ‘You da man!’” “Oh, that’s just Tony the doorman,” I say shaking my head.  “Don’t listen to him.  He says that all the time.” ………………………………………………………………………………………………………………………………………………………….   I pick up a chart in the ER, back when there still were things called “charts”, and it says: “Tony ***** 37-year-old male.  Chief Complaint: Back Pain.”  I walk in the room and it is Tony the doorman of my apartment building, nervous, sweaty and pacing the room, with his jet-black hair slicked back and his gut as huge as always. “Tony!  How are you doing?  Good to see you.  What brings you in here, today?” “Doc.  You gotta’ do somethin’.  My back’s killin’ me.  I’m dyin’ here,” he says in his tough-guy accent, as he nervously paces the room. “Where does it hurt?” I ask. “Right here,” he says, pointing to his upper back, “right between da shoulder blades.” “When did it start?” I ask. “Just a couple hours ago.  I didn’t do nuttin’.  I was just sittin’ there and it hit me like a ton of bricks.  I didn’t fall, lift anything heavy or hurt myself at all.  I’m dyin’ here doc.  You gotta help me.  I need something for this pain,” says Tony. “What does it feel like?” I ask. “It feels like someone’s got a sledge-hammer on my back.  Seriously, man.  I’m dyin’ here.  Come on.  Do something doc.  Make this pain go away.  I need something for this pain.  Please.” “Is there anything that makes it any better?  Anything that makes it hurt worse?” I ask. “Nope,” he says. “Does the pain move?  Does it radiate?” I ask. “No,” he says, “it’s just right there in da middle of my back?” “By chance, is it a ‘tearing pain’ right between your shoulder blades?” I ask. “Not really,” he says, “it just hurts!” My gut is telling me that something is not as it appears.  I have the nurse give Tony a dose of Morphine while I continue to get the history.  Tony proceeds to tell me that he doesn’t drink, smoke or use any illegal or prescription drugs.  Also, he reports no significant medical problems, and no significant family history.  He also denies any history of chronic pain of any kind.  His physical exam is completely normal including his vital signs with equal blood pressures in both arms. “Alright, Tony, the nurse is going to give you another dose of the pain medication.  We’re going to get a chest x-ray and see what that shows.  I’ll be back in a few minutes,” I tell him.  My gut is telling me, that there is something Tony is not telling me, but my brain is telling me that if Tony’s upper midline back pain is from a thoracic aortic dissection, and he dies from it, I’ll never forgive myself. “Doc, it’s starting to hurt right here,” Tony says, pointing to his chest. Bingo, I ...

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Healthcare Update 08-10-2012

Good thing the government is going to make sure everyone has INSURANCE. Now good luck finding care. Nearly one third of doctors won’t take government’s Medicaid insurance. If you live in New Jersey, only 40% of doctors accept Medicaid. This same issue was raised years ago and no one paid attention. Now we’re all getting what we wished for. One huge difference between health care systems in the US and Great Britain … in the US you get taxed to receive insurance, in Great Britain, you get taxed to receive health care. The first thing I thought when I read this study was that a man must have been the author. Doctors hypothesize on way for women to combat morning sickness. You’ll have to click the link to read more about it. This is a family-oriented blog. This will teach you not to do the dishes. Delaware doctor accused of sticking his daughter’s head under the kitchen faucet to “waterboard” her. Of course the daughter was known to have made false claims of abuse against a half-sibling in the past, but Delaware officials ordered an emergency suspension of the physician’s license after a complaint was filed by the Delaware attorney general’s office.

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Healthcare Update — 08-06-2012

Finally some proof! We CAN’T sue our way to better health care. Choke on that, American Association for Justice. Largest medical malpractice verdict in Colorado history handed down last month. $15 million awarded to 36 year old man who came to the emergency department with neck pain, numbness, and tingling in his arms and legs, who was discharged with a diagnosis of a “neck strain,” and who suffered complete paralysis a few hours later due to a herniated disc that was compressing his spinal cord. Another hospital turning its emergency department into a daytime acute care clinic. Boothbay Harbor, Maine’s emergency department only averaged about 11 patients per day. Now emergencies will have to travel an extra 20 miles to the next closest emergency department.

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A Nameless Faceless Killer

By BirdStrike M.D. 1) A 40-year-old female sees her family physician for burning chest pain after she eats hot peppers. She had it only once while exercising. Her family physician sends her to the emergency department and she gets admitted for chest pain. Rather than going home with treatment for her GERD, she ends up dead. This never should have happened, but the family never learns what really killed her. 2) A 33-year-old father of 3 dies on a hospice ward, bloated with steroids, on tube feeds with a tracheostomy. He was stricken down too young, his family is told, by a rare form of brain cancer. It was an unlucky fluke, they are told, but that is not the only reason. 3) A 7-year-old boy dies in the Pediatric ICU. His family is stunned, shocked and devastated. How could this have happened? The family is told he died from an ingrown toe-nail infection that spread to his blood stream and caused a severe form of sepsis. “It could happen to any of us.” They do not know that the breeding of this superbug was fed by a nameless killer. 4) A 16-year-old girl is on a CT scan table nervously giggling. Fifteen minutes later, she goes into cardiac arrest. A short time later, a solemn nurse informs her family that the patient has died from an allergic reaction. But her cause of death is something more insidious. Each of these patients had a different doctor, but a similar contaminant. Much like a baseball slugger whose home run swing at a 100 mph fastball is thwarted when a camera flash from his biggest fan causes him to blink; the doctors were thrown off of their game. The culprit: Defensive Medicine. In each case presented, the doctor had a very rational fear of being sued for either making a mistake or even for doing everything right. During the last moment in the rapid-fire decision-making process, each doctor had a “flash in the eye.” In each case, the result was a swing and a miss. Over and over, and over again in hospital wards, emergency departments, operating rooms, and doctors’ offices in America doctors are being told they must rule out every possibility or be sued. The ones who suffer are the patients, often tragically so. Why? Rather than trusting their instincts, the treating physicians are instead asking themselves, “What could a medical malpractice attorney possibly say I should have done?” While this may seem like a dangerous way to practice medicine, often the doctors have very little choice but to do so.  Consider the stories behind the cases presented above:

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