Mine's Bigger

People associate doctors with many things, but by far and away the most commonly associated objects with doctors are...

...needles.

Small needles. Fat needles. Long needles. Short needles. It doesn't really matter. No one likes them.

Needles have lots of uses from (1) removing fluid or small bits of tissue from locations within the body or beneath the skin, (2) injecting medicines or fluids beneath the skin or directly into the vascular system, or (3) poking holes in things to permit passage of slightly larger plastic tubes over them. They are sized by "gauge" sizes - usually larger numbers mean smaller diameters.

But what many don't know is the relationship between doctors' specialties is directly correlated to the type and size of needle they use.

The Dermatologist - Even though they work on the largest organ of the body, it seems everything's smaller in dermatology: warts, skin tags, basal cells. And they don't like scars. Resecting these takes a little local anesthetic delivered by, you guessed it, tiny 25-gauge needles, shown here:



The Pediatrician or Oncologist - These guys have a knack for flare, but they're still dealing with tiny veins, so they've devised the cutest of the needles called the "butterfly" needle:



The Internist - Nothing can be simple for internists, so the "Angiocath IV" was invented. It's a smaller needle with a thin plastic tapered tube over it that follows the needle into the vein, provided, of course, this doctor was trained earlier by a really good nurse. Otherwise, the plastic tube will rest outside the vein and permit intravenous (IV) fluids to be poured into the space beneath the skin, swelling the hand to the size of a small softball. So placing intravenous catheters ("IVs") takes a moderate amount of skill and a steady hand:



The Orthopedist - All it takes is a strong arm, a heavy hand, and just about any orifice in the body can be reached by an orthopod with this thicker, sturdy, 18 gauge needle:



The Cardiologist - By far and away, the workhorse needle is the Cook or Seldinger needle. It's also 18 gauge, but it's longer length helps reach the femoral artery in the upper leg region. (Yes, the othopedist could reach this with his shorter needle, but cardiologists don't like to push so hard). This needle's thinner wall and larger diameter permits passage of a thin wire within the lumen of the needle into the artery. The needle is then removed and a short plastic straw-like structure (called a "sheath") can be passed over the wire into the artery. For such a novel task, it has a strong, commanding look:



The Emergency Room Physician - Not to be outdone by the meager Cardiologist, Emergency Room physicians' trademark needle is the spinal needle. It's a bit longer than the Cardiologist's needle and handy to puncture the lower back to enter the spinal canal (getting lightheaded yet?):



The Cardiac Electrophysiologist - But ER doctors have nothing on the Electrophysiologist. Poking a hole in the heart by passing it from the upper leg area takes a very special needle. And with atrial fibrillation ablation procedures performed in the left atrium, this is the workhorse of today's electrophysiologist. Pioneered by E.C. Brockenbrough to puncture from the right atrium to the left atrium, this needle is the granddaddy of them all.

And what can I say, except...

...mine's bigger:



Yes, ladies and gentlemen, size does matter.

-Wes

Reverse Medical Tourism

There has been a lot of buzz about losing patients overseas to other cheaper venues to deliver care, but we must not lose sight that America still has significant expertise in areas where world leaders come to gain access to our healthcare system, especially when it involves expensive devices or therapies.

Lech Walesa, Poland's former President and Nobel Peace Prize winner who was instrumental at struggling against communism, has sought treatment at Houston's Methodist Hospital for congestive heart failure. The Houston Chronicle reports:

Former Polish President and Nobel Peace Prize winner Lech Walesa is scheduled to be fitted with a pacemaker at a Houston hospital today, a day after tests left doctors hopeful he won't need a heart transplant anytime soon.

Walesa, 64, underwent tests at The Methodist Hospital on Tuesday for advanced heart failure. He traveled to Houston from Mexico, suffering from shortness of breath and fatigue that had caused some doctors to suggest he might need a transplant.

"The struggle with communism took a lot out of my health," said Walesa, speaking through a translator. "But to be part of the discussion regarding remaining questions, I need to be healthy."

Walesa also has significant lung disease, Methodist doctors said.

They didn't rule out that Walesa might eventually need a heart transplant but said such a scenario isn't on the horizon now. Emphasizing that they think Walesa's heart can be strengthened, they said most patients who get a pacemaker don't go on to need a transplant. Only if his heart worsens will they evaluate whether he needs a new heart, they said.

The doctors said they hope Walesa can be discharged from Methodist early next week.

My bet is he won't receive just a pacemaker, but a biventricular implantable cardiac defibrillator in hopes that he'll gain benefit in his left ventricular function and shortness of breath. Data from the MIRACLE trial using biventricular pacing for severe heart failure in patients with markedly reduced ejection fractions and widened QRS complexes demonstrated symptomatic improvement in about 66% of patients. The CARE-HF trial also demonstrated a mortality benefit with biventricular pacing alone, while the COMPANION trial demonstrated superior mortality benefit to biventricular pacing coupled with a defibrillator when compared to beventricular pacing or drug therapies alone.

Who'll pay for this device and his care is another question: will it be former-President Walesa, the State Department, or Methodist Hospital? Will his device be donated by a device company for PR purposes?

I wonder how this is handled in these cases? Should VIP healthcare be different than that received by the average Joe here in the States?

-Wes

UPDATE: 1 Mar 08: An ICD it was.

Senator Warner Has Atrial Fibrillation Recurrence

Senator John W. Warner (R-Va.) had to go back in the hospital for management of atrial fibrillation. Seems he had a "non-surgical therapy that was deemed successful" (cardioversion?) in October. He joins the ranks with the most common arrhythmia known to man.

Now that he's recurred, what options for therapy exist?

Well at age 81, many.

His best therapy will be determined by his symptoms. Anticoagulation is likely to be started, tho' it will depend on his other medical issues. The recently-published ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults With Nonvalvular Atrial Fibrillation or Atrial Flutter outlines the use of the CHADS2 score (Cardiac failure, Hypertention, Age over 75, Diabetes, and Stroke [doubled]) as a point scale to assess who needs the blood thinner warfarin. Scores greater than one typically are treated with warfarin.

Beyond this, his heart rhythm management is kind of like Goldilocks and the Three Bears: if his rate is too slow, a pacemaker might be in his future. If his heart rate is too fast, medications (like beta blockers or calcium channel blockers) might be used to slow the heart rate. If the irregularity of the rhythm bothers him, then catheter ablation or a rhythm control drug (like Amiodarone or Dofetilide) might be used (the later of these two requires a 3-day hospital stay to initiate the drug). Of course, another cardioversion could be performed as well, but his arrhythmia has already proven it's likely to recur.

In and of itself, atrial fibrillation can be well-tolerated if the heart rate is well controlled. Hopefully he'll do well and have a short hospital stay.

-Wes

Want more about atrial fibrillation? Feel free to peruse my Atrial Fibrillation Tutorial - it's better than any sleeping pill out there.

Healthcare Bill: $4.3 Trillion in 2017

Call me a cynic (who me?), but it seems with this news that the upcoming 10.1% pay cut in June for physicians won't be enough:

Government spending on health care could nearly double by 2017 to more than $2 trillion, according to a new federal study, reflecting a surge that promises to complicate the campaign debate about health care.

Driven by the aging of the baby-boom generation and rising costs of new drugs and medical technology, Medicare, the big federal health program for the elderly, will take up 20.7% of national health spending by 2017, according to the report.

Overall, the report projects health-care spending in the U.S. will hit $4.3 trillion by 2017, nearly double the 2007 amount.

Heck, why not make it an even 20.7% to keep costs the same? After all, doctors are clearly the cause of the problem.

-Wes

Cubs' DeRosa and the Management of SVT

Mark DeRosa, the Cub's second baseman, was reported today to have flown back to Chicago from spring training in Mesa Arizona to be "examined by a cardiologist at Northwestern Meemorial Hospital, but only expects to miss one week of camp."

That should be about right. After all, he has a very curable condition called "SVT" - short for supraventricular tachycardia.

My bet: he'll be "cured" before the close of business today and use the rest of the week to convalesce.

On second thought - he'll probably be playing again Monday.

Most likely, he has garden-variety AV nodal reentrant tachycardia, a loop-the-loop heart rhythm caused when two halves of the normal AV node (which connects the top and bottom chambers of the heart electrically) create a circular path around which the electricity can travel quickly - to the tune of about 150-200 beats per minute typically. One pathway usually conducts quickly, and the other, more slowly. The fact that he can do "manuvers" to stop the rhythm (usually a "Valsalva maneuver" - forced expiration against a closed mouth) - is very suggestive that this is this cause for his racing heart beats. The straining maneuver causes slowed conduction through the pathways, but the slower-conducting pathway occassionally stops its conduction briefly, allowing the regular rhythm to resume.

Catheter ablation, or cauterizing (burning) the slower-conducting pathway in the AV node, when performed correctly, has a very high cure rate and relatively low complication rate, but involves about a two- to three-hour procedure where wires are passed throught the veins in the legs to the heart, and the location of the slow pathway cauterized to destroy the extra-conducting pathway. No long-term medications are required. Certainly, for the person unwilling to risk the procedure, medications (like beta blockers or calcium channel blockers) can be used to help control the arrhythmia by blunting heart rate response - not a likely scenario for a pro-baseball player to accept.

I wish Mr. DeRosa the best of luck, and look forward to seeing him back on the field soon.

-Wes

UPDATE: 27 Feb 2008 17:00 - It's sometimes nice to say I told you so. (Heh, this wasn't a tough call - but I think DeRosa's making the right choice here...)

ADDENDUM: 1 Mar 2008: All's well that ends well.

Jarvik's Out - Idiocy is In

Well, Pfizer pulled the million-dollar man, Dr. Robert Jarvik, from its pharmaceutical (Lipitor) ads today due to "misimpressions." It's just too risky to use a make-believe clinical doctor, I guess.

Instead, we can look forward to more beavers, butterflies, and animated pipemen to promote drugs more objectively.

Hell, I see butterflies in my bedroom when I take Lunesta, don't you? Especially since they paid over $182.7 million in the first half of 2007 to make sure I see them over and over and over again...

-Wes

Pacemakers, Defibrillators, and Hybrid Cars

With the interest and popularity of going "green" with hybrid cars (even with a select few of my fellow physician-bloggers) I thought it would be worthwhile to share a few tidbits about the potential for electromagenetic interference between hybrids and pacemakers or defibrillators. (Heck, maybe they'll need this info when they get older and have their pacer installed...)

There's been some recent reports of people returning their Toyota Prius or Camry Hybrid, Lexus GS450h, or other newer hybrid cars due to fears over interference with these cars' "smart keys" (which detect when the key is within three feet of the car) and pacemakers or automatic defibrillators. It seems these cars' smart key antennas transmit at frequencies of between 119 and 135 kHz with a relatively low power. Still, because of the wonders of physics, if a pacemaker or defibrillator were sufficiently close to one of these antennas, then there could be the potential for interference. But is there enough of a risk to trade back in a car?

Once again, it seems more devices are being developed out there than the pacemaker and defibrillator device manufacturers can test sufficiently to assure that nary an issue exists with outside electromagnetic interference. One only needs to look at the recently popularized iPod interference issues or the disclaimers on the Nintendo's Wii gaming system to see how far the hysteria can go.

So before more scary press releases occur, I called some pretty smart "engi-nerd" types from the manufacturers (Note: I use the term "nerd" here with respect, since I are one) to find out a bit more about the potential for excitement in people driving hybrids with pacemakers or defibrillators. Here's the basic gist:

Medtronic: Hybrid Cars: Cars that are powered, at any one time, with either batteries, gasoline or both.

"Gasoline engine: Maintain a 12" (30 cm) distance from the components of the ignition system of the gasoline engine and the Pacemaker or ICD. If closer than 10" (30 cm), there is the potential for Pacemaker reversion or inhibition and for ICD shock.

Electric power components: The DC/AC current used to power the electric motors and the permanent magnets associated with the motor operation can affect the Pacemaker or ICD. Maintain a 24" (60cm) distance between the electric motor and the implanted device. If the device is closer than 24" (60cm), there is the potential for Pacemaker reversion or magnet rate operation or disabling of ICD detection circuit or ICD shock."

St. Jude Medical:

"Cardiac pacemakers are electronic devices with sensing circuits designed to detect small electrical signals from the heart. Pacemakers may detect extraneous electrical signals from sources other than the heart and incorrectly interpret these signals as heart activity. Inhibition of the pacemaker, resulting in no output pulse to the patient's heart or reversion to asynchronous pacing may result. At this time we have no reports of large-scale electrical motors or generators affecting our pacemakers. However, this does not mean there is a total absence of affects related to electric motors of several hundred horsepower. Extraneous radiated noise from large-scale electrical motors will not cause damage to your pacemaker. If large-scale electrical motors do affect the pacemaker, inhibition or reversion to asynchronous pacing may potentially occur. Some patients can tolerate reversion to asynchronous pacing or some inhibition of their pacemaker. Any problems caused by radiated interference will end when the electrical interference ends or the patient leaves the immediate area. The risk of working with large-scale electrical motors may be reduced to an
acceptable level by observing proper techniques. Working on the motors with the power “OFF” will avoid electrical interference. In the power generating plants I have visited, the large motors and generators have been grounded and shielded which minimized the radiation of electrical noise."

Boston Scientific:

They recommend a 9 inch (22 cm) clearance from a smart key to any of the antennaes on hybrid cars. This more conservative distance was recommended by the Japan Association of Medical Equipment Industries' (JAMEI)(a la, Toyota) rather than Boston Scientific. It seems they are still in the process of their own testing. Boston Scientific's recommendations regarding smart keys and their devices, with diagrams of where the transmitting and receiving antennaes are housed, can be found on Boston Scientific's website (pdf file).

In summary with smart keys, there seems to be a consensus that the risk of interference with pacemakers or defibrillators is low, especially if the smart key is not left near the device (i.e., in a shirt pocket). Most felt the power of these "keyless" devices was sufficiently low (like the iPod, Wii, or cell phones) to limit concerns over their interference with pacemakers or defibrillators provided some common-sense distance precautions were maintained.

Regarding interference with the electric motor components of hybrid cars, two manufacturers have recommendations regarding being too near the engine and that operating a hybrid car should be quite safe, as long as the operator with a pacemaker or defibrillator does not try to become the mechanic for their own car.

-Wes

When It Comes to Prevention: First, Do No Harm

"An ounce of prevention is worth a pound of cure."

- Ancient proverb

* * *

“About 95 percent of our plans are similar. We both set up a government plan that would allow people who otherwise don't have health insurance because of a preexisting condition, like my mother had, or at least what the insurance said was a preexisting condition, let them get health insurance. We both want to emphasize prevention, because we've got to do something about ever escalating costs and we don't want children, who I meet all the time, going to emergency rooms for treatable illnesses like asthma.”

- Sen. Barack Obama, Democratic Debates 31 Jan 2008

* * *

"We're going to make sure that we reduce costs by emphasizing prevention."

- Sen Barack Obama, Democratic Debates, 21 Feb 2008

* * *
What does this line really mean in the health care debate: “We both want to emphasize prevention, because we’ve got to do something about ever escalating costs…” Would “prevention” have prevented Sen Obama’s mother’s pre-existing condition? Of course not. So why do we hear this?

Simple: because it sounds reassuring. It'll all be handled. Really it will.

But do "prevention" programs really reduce costs to our health care system? Can people with cancer or heart disease or pneumonia or multiple sclerosis “prevent” their disease? Can people “prevent” getting older? Can all accidents be “prevented?” How about arthritis or diabetes? Can we prevent their onset? Can government force people to eat less or stop smoking? Would we want this? Or in the case of the much ballyhooed genetic testing – can people really “prevent” a genetic disease from developing? As a doctor, I’d love to prevent all disease that afflicts man, but I know this is impossible. I rarely see patients until they have a problem - people just don’t want to think they could become sick.

But new “prevention” initiatives are underway by healthcare insurers who “reward” (bribe?) their policy members with financial incentives to participate in weight reduction classes and to stop smoking. We are told this will keep costs down. But the overall benefit to reducing costs to our healthcare system has not been clearly demonstrated. On the contrary, a recent study in the obese evaluated the lifetime costs of this disorder and concluded that although annual health-care costs are highest for obese people earlier in life (until age 56 years), and are highest for smokers at older ages, the ultimate lifetime costs are highest for the healthy (nonsmoking, nonobese) people. Hence the authors argue that medical costs will not be saved by preventing obesity. Could it be that cost savings are actually for the insurers who identify those “at risk” as defined by their industry’s own actuarial tables rather than real data?

Even with heart disease, we are now questioning the low LDL hypothesis and the use of statins as a means of improving myocardial infarction outcomes through lowering LDL levels in the blood. Certainly, most clinical cardiologists and primary care physicians do perceive that there is a reduction in the number of large Q wave myocardial infarctions recently. But why? Is it the statins? Or is it the implementation of anti-smoking legislation? Perhaps it’s because people are thinner. Or are they? It certainly couldn’t be because people are fatter – or could it?

Huge monies are involved in promoting therapies and testing for prevention. Companies need to “get the word out” to sell their wonder drugs and scanners. Nowhere is this better illustrated than the marketing of Gardasil by Merck to “prevent” cervical cancer. While the drug is good for specific forms of preventing cancerous precursors caused by the human papilloma virus, it is not perfect, since it immunizes for only four strains of human papilloma virus (6, 11, 16, and 18). But in an attempt to achieve perfection, boys are being considered as potential recipients of the vaccine – all at significant cost to our healthcare system. How many other viruses should we be similarly immunizing against? What would the cost be to our society?

What is clear is that programs and tests to perform “prevention” are consuming huge health care dollars – from advertising, marketing, frequent doctor visits, early CT scans, carotid ultrasounds, lipid monitoring, mammography, colonoscopy, genetic testing – all of these are expensive (and becoming more so). Just diagnosing something earlier – does that save healthcare costs or increase them overall? Early diagnosis might prevent later complications of disease, to be sure. But it might also increase the contact with the healthcare system and extend expensive treatments. Early diagnosis also provides a convenient means for insurers to deny a patient coverage if they change jobs. This might save the insurers costs, but the patient? Will this activity ultimately save overall healthcare costs or increase them? Also, additional earlier diagnosis might prolong the time until a definitive surgical cure takes place – adding additional follow-up costs. Finally, in the case of the dying, isn’t death remarkably economical to our healthcare system?

So before claiming that “prevention” programs will be our way of controlling healthcare costs, we should stop and ask if these programs save money or waste it. To do otherwise will doom our healthcare system to continued escalating costs in the name of "prevention."

Remember, when it comes or promising "prevention" programs as a means to save healthcare costs: Primum non nocere. (First, do no harm).

-Wes

Reference: Cohen JT, Neumann PJ, and Weinstein MC. Does Preventive Care Save Money? Health Economics and the Presidential Candidates. New Engl J Med 14 Feb 2007; 358 (7): 661-663.

Our Latest Recipe

Take one part travel, add two parts time, three parts unforeseen costs (airfare, hotel, car rental fees, meals, oversized-luggage fees), four parts of 15-minute auditions, and five parts stress. Add them to a pot containing one high school senior who’s clueless as to what it takes these days to gain a college acceptance in his chosen field of performance music (cello). Puree with a two-month timeline where frantic families cross paths repeatedly at the same schools.

Add an one ounce uncertainty and two of anxiety.

Stir.

The result?

Yum. (Rated G: but not for the faint of heart).

-Wes

Ref: Image credit.

Doping Doctors

It's a move that will make even Major League Baseball's Roger Clemens and Andy Pettitte take pause: doping doctors.

It seems there is a "crisis" afoot in America's hospitals: in-hospital cardiac arrests. According to the American Heart Association (AHA)'s National Registry of Cardiopulmonary Resuscitation (NRCPR) investigators and now rocketed to the media to increase the fear factor:

In-hospital cardiac arrest is a major public health problem. During 2005 and 2006, more than 21 000 in-hospital cardiac arrests were reported to the AHA NRCPR from approximately 10% of the hospitals in the United States. The principal finding of this study was that survival to discharge following in-hospital cardiac arrest was lower during nights and weekends compared with day/evening times on weekdays, even after accounting for many potentially confounding patient, arrest event, and hospital factors.

In an amazing move to justify their existence, the investigators' cardiac arrest database has identified the obvious: hospital wards staffed by the lowest numbers of individuals who have received the short-straw of night and weekend duty because of their junior status have poorer outcomes during cardiac arrests.

Well no kidding, ace. We needed a study to show this?

It seems so. Bureaucrats need to find things to "improve" in their ever-expanding quest to raise the cost of providing healthcare to our sick and injured while securing their fitful place in the Quality Assurance Hall of Fame.

But what was truly scary is not the problem; it was their solution proposed to fix this "major public health problem:"

Night staff proficiency in cardiac resuscitation could be enhanced by additional training, such as "mock codes" and cardiac resuscitation simulation training. Chronobiologic scheduling, naps, or use of medications such as modafinil may also improve nighttime staff performance.

That's right. Dope the doctors and the nurses.

These investigators, at a loss to offer concrete staffing solutions, feel the use of drugs is the way to go. They reference two other studies: one in ER doctors and the other from sleep researchers touting the benefits of modafinil. Never mind that this drug prevents fitful sleep. It seems there is a move afoot amongst our clipboard-carrying colleagues to promote performance-enhancing drugs as a means to improve physician and nursing performance in all sorts of arenas.

I can see it now: George Mitchell will soon be hired by the hospitals' Bud Selig look-alike, Richard Umbdenstock, president and CEO of the American Hospital Association. Patients will be aghast at the findings. News media lights will shine. The scandal will be exposed. Performance enhancing drugs will "sully" the very game that is healthcare today. Doctors will be called before Congress, or worse: called to the witness stand to explain their drug-seeking behaviour to a jury of their peers.

Ridiculous, you say?

Not really. It is a sad commentary that there are really bozo's who think that the use of drugs should be condoned to improve outcomes in cardiac arrest.

That, my friends, makes my heart stop.

-Wes

Reasons Enough

... to take a vacation:





-Wes

Concierge Cardiology

Parked in the airport with a delayed flight I came across this tidbit: it seems concierge medicine now is extending beyond primary care into specialty practices:

Now, the Naples market is seeing concierge practices in cardiology, pediatrics, obstetrics/gynecology and physical therapy.

Dr. James Buonavolonta, a cardiologist, worked in traditional practices for years before starting Concierge Cardiology of Naples in February 2007.

“(Before) I had a few thousand patients. I felt like I was not giving them the time they deserved of a cardiologist,” he said. “That’s not why I went into cardiology.”

Now he will limit his practice to 150 patients and has nearly reached it. His patients run the gamut of cardiology needs, from those with congestive heart failure to others who want to prevent problems. Today, he sees 5 to 7 patients a day.

“I have patients in their 40s with cardiac risk factors who want to keep an eye on things with a strong family history ... (where) a parent had a heart attack at 50,” he said.

In the first year after starting his concierge practice, 5 percent of his patients needed a hospital stay, a low number which he attributes to better follow-up care.

“The ability to have access to your cardiologist is so reassuring to patients,” Buonavolonta said, adding that if a patient has something in the middle of the night, they call him first rather than heading for the emergency room.

With patients who are willing to be part of a concierge practice, they are more likely to be compliant with their doctor’s treatment course, he said.

Not all his patients are wealthy, which he and other concierge physicians attribute to people’s dissatisfaction with mainstream medicine and not getting the care they want.

“I do have regular people with regular jobs, and feel their medical condition is a priority in their life,” he said.

Wow. Five to seven patients a day? Seems a bit light to me...

But the point to be made here is concierge medicine is now happening to specialists, too. The reasons for this migration are probably multifactorial: (1) declining Medicare reimbursements for procedures, (2) declining revenue streams for office visits, (3) more basic medical issues being managed by specialists due to lower number of primary care physicians, (4) insurance reimbursements being less than market rates, and (5) inflation - all serve to force specialists to rethink the status quo.

The times, they are a changin'...

-Wes

Blog Break

I'll be heading to a warmer climate tonight for some R&R and recoup time (should be good for my back). I might not be posting as consistently, but I'll be back in force Wednesday.

-Wes

My Valentine's Story

It was just your routine defibrillator check at first. Then the screen showed the device had fired.

"You mean I was shocked?"

"Yep."

"When?"

"Three weeks ago, on the 23rd, at 06:38AM and 12 seconds."

"But I didn't feel anything. Just a minute, let me check my calendar." She flips through her calendar, mind scrambling. "I was in Florida. That was the day I went to the spa. I felt fine."

"Remember when you got up that day?"

Hestitating. "I'm not sure. I never had a shock before. Are you sure this thing fired?"

"Yep. Here's what the device recorded:"

(Click to enlarge)

"Why did this happen?"

"I'm not sure. As you know you have atrial fibrillation and a weak heart muscle though you were never found to have coronary artery disease (blocked arteries) - that's why the defibrillator was installed."

"Yes."

"Well, if we look at the tracings, I notice two small clues as to what happened. See those little VS notations?"

"Yes."

"Well those occur every time one of your heart beats are sensed by the device. If there's an FS, that means a heart beat was detected that was above the ventricular fibrillation cutoff rate (in other words, it was going really fast). The TF also means that the heart rate fell into a very fast ventricular tachycardia zone. A VP notation means the device paced your heart. Now, see the 'FD' as the first label on the bottom of the seond line of tracings?"

"Yes."

"Well that means that enough fast heart beats occurred to satisfy the device's algorithm to call this rhythm ventricular fibrillation - the FD stands for 'Fib Detect.' Note how the device then stops labelling the sensed ventricular beats as FS's as it charges to deliver a shock(the labels turn back to VS's but the rate still looks really fast.) Once the charge ends, a CE label is displayed. The device looks for one more fast heart beat, and when it sees it, it delivers its charge, labeled as 'Charge Delivered,' or CD on the next sensed rapid ventricular beat to reset the rhythm. That's when the shock occurs that most people feel. Then we can see your own normal ventricular sensed (VS) beats after the shock is delivered."

"Amazing."

"Yes ma'am, it is. Happy Valentine's Day."

"Oh my God, you're right! I can't believe it! I really just can't believe it!"

* * *
So what programming change was made to her device to prevent another shock? It was a single-chamber Medtronic ICD programmed with backup ventricular pacing at forty beats per minute.

Any takers?

-Wes

Addendum: For those not accustomed to viewing the information produced by interrogating a defibrillator after a shock, the top two lines on each strip represent the signal seen (1) from the tip electrode to the can of the device, simulating an EKG lead, and the lower line (2) is the signal seen locally inside the heart between closely spaced electrodes on the lead (these lines are not "on" at first until a rapid rhythm is detected). The lowest line is the "marker channel" that demonstrates how each blip on the middle signal line was interpreted by the device.

Sleep Deprivation and Sleeping Pills

My thoughts on this topic are up over at MedPage Today.

-Wes

What the Hell's Going On at My Alma Mater?

Duke's in hot water again - more strippers and worse.

To think my daughter wanted to attend her Dad's alma mater: no frickin' way. And that check I sent each year? Consider 'em cancelled.

-Wes

h/t: Overlawyered.com.

Gotta Love This

...and just in time for Valentine's Day.

-Wes

Statins, Cognitive Effects, and Gender Bias

It's surfaced again: the effects of statins (specifically atorvastatin or Lipitor) on the cognitive functioning of the brain. Today's Wall Street Journal quotes Dr. Orli Etingin, vice president of New York Presbytarian Hospital who states "This drug makes women stupid." He goes on to say:

"I've seen this in maybe two dozen patients," Dr. Etingin said later, adding that they did better on other statins. "This is just observational, of course. We really need more studies, particularly on cognitive effects and women."

Now is this about the drug? Or is this about supporting research for women? Why would women be affected and not men? Are not our brains made of the same cholesterol-based myelin mush? Or is their a societal bias against men who must never become confused or depressed? Certainly, the relative benefits of statins for reducing acute coronary syndromes has been well-studied, but the challenge with measuring cognitive effects of these medications (or any other medication) are considerable and less conducive to increasing sales. So I would ask that before we bias these statements toward women, we also consider statins' effects on men, too.

Better yet, before panicking, we should consider that this cogitive effect might just be a side effect of the medicine, just like nausea, muscle aches, or any other side effect, and appears reversible if the drug is stopped. Doctors and patients alike should look at it this way and not generate undue anxiety over this news while carefully considering the risks of recurrent heart injury to cognitive decline. Only then with such a careful assessment can recommendations be made to the risks and benefits of these medications in an individual patient.

Well, I better warn my office staff today - no doubt we'll be hearing the phones ring like crazy...

-Wes

Ref: More info at: www.statineffects.com.

Shaking Things Up

If you want to mess with the healthcare system of today - play with cost transparency. Carol.com does just that:

(CNN) A new Twin Cities company called Carol is trying to change that with a Web site that gives consumers a "care marketplace" to search for medical services, compare quality and price and make appointments.

Carol joins an effort to transform the U.S. health care system by putting consumers in charge and letting the market do its work.

"We want to let consumers define value," said Tony Miller, Carol's founder and chief executive officer. "We don't have care competition in the marketplace today."

The free site, which went live in January, generates revenue from health care providers who become "tenants" on the site. When a consumer sets up an appointment with a clinic or doctor on Carol.com, the provider pays the site a fee.

It is interesting to look at the responses of the nay-sayers:

But Dr. Sidney Wolfe, director of Public Citizen's Health Research Group, said the site is nothing more than advertising, and he hoped it wouldn't catch on.

"Among physicians, there's a belief that health care is too critical ... to be left to the usual marketplace," he said.

. . .

If the site becomes more comprehensive, Carol.com would be most useful to people with high-deductible plans, health savings accounts or those without health insurance, said Elizabeth Boehm, an analyst with Forrester Research who studies the health care customer's experience.

She was skeptical of the site's prospects because many people's choices are limited by their HMO.

"(Price is) just not what drives people to make their health care choices," Boehm said. "The challenge for a site like this is that while conceptually it's good ... the reality is there are only a small group of customers looking for that."

Baloney. With patients being responsible for more and more of their out-of-pocket healthcare costs, I believe this idea will catch on like wildfire.

It is interesting that the Park-Nicollet Clinic in St. Paul joined forces with the website developer. It is no secret that this healthcare system has struggled in the past to compete the competetive Twin Cities healthcare marketplace. By competing head-to-head on price, they may have found a new way to attract more patients in to their system. This in turn, may force others to follow suit or to undercut their prices (which would be good for consumers). As the company's founder and CEO, Tony Miller states:

But Miller said consumers are starting to realize that choosing cheap health care might come back to haunt them in the form of higher premiums or other increased costs. And he thinks there are plenty of people like him who might want different options for care and are willing to pay more out-of-pocket to get what they want.

He said his idea for Carol came in part from his own experience with a heart condition for which he was told he needed surgery. A second professional recommended medication, which Miller, 41, said worked.

"I had the wherewithal and some of the contacts to help me navigate and find answers in the health care system. Most consumers don't have that," said Miller, a partner in the venture capital firm Lemhi Ventures, which has invested $25 million in Carol.

Although the number of ailments are almost overwhelming to review, I found it interesting to shop by price alone for things like a root canal, asthma treatments, or what one place is charging for a cardiac CT to obtain a calcium score that throws in "free parking close to the door!"

While the number of "tenants" on the website are small now, look for this idea to grow as smaller, less known healthcare services compete head-to-head with the Big Boys of healthcare.

-Wes

Online Doctor Visits?

It seems so:

In recent weeks,Aetna Inc., the nation's largest insurer, and Cigna Corp. have agreed to reimburse doctors for online visits. Other large insurers are expected to follow, experts say.

These new online services, which typically cost the same as a regular office visit, are aimed primarily at those who already have a doctor. The virtual visits are considered best for follow-up consultations and treatment for minor ailments such as colds and sore throats.

Wow, we don't even have to see people anymore to be a doctor.

Sore throat? Treat it. Swollen glands? Treat it. Dysuria? Treat it.

Never mind that antibiotic resistance is already a HUGE problem - it's CHEAPER and MORE CONVENIENT people! (At least at first.) Methicillin resistant staph? Vancomycin-resistant enterococcus? Clostridium dificile? Let's rock and ROLL! Prescribe, baby, prescribe! Let's see if we can make even more potent organisms! Lets give EVERYBODY antibiotics. Hell, why not just sell 'em over the counter? Who needs a doctor anyway?

But seriously. Online doctoring will be great for the majority of minor ailments and the payment structure, if true, might be a much-needed boon for primary care. But there are serious limitations that liability lawyers will love to exploit. Like what about the sore throat that is really epiglottitis? Or the dysuria that is caused by an drug-resistant STD?

Will the insurers pick up my higher liability payments that might result from missed online diagnoses, too?

-Wes

Quality Report Cards Get an "F"

Surprise, surprise:

For the Annals article, researchers from RAND Health in Santa Monica, Calif., and the Veterans Affairs Greater Los Angeles Healthcare System examined peer-reviewed studies evaluating the impact of public reporting on the quality of health plans, hospitals and physicians.

The study found that "evidence is scant, particularly about individual providers and practices" and that "rigorous evaluation of many major public reporting systems is lacking." The authors said "the effect of public reporting on effectiveness, safety and patient-centeredness remains uncertain."

I can't tell you how many "quality" reporting systems still report that I am credentialed at hospitals from other states in which I no longer carry an active license.

Bottom line: No one is checking the credibility, timeliness, and accuracy of the data generated in these "quality report cards" and, like computers, it's "garbage in, garbage out."

As doctors, we can only hope that patients will rapidly abandon these resources once this ruse is exposed.

-Wes

Reference: Fung CH, Lim Y, Mattke S, Damberg C, Shekelle PG. "Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care." Annals of Internal Medicine 15 January 2008; 148(2), Pages 111-123.

* * *

Addendum 05:30AM CST 11 Feb2008 - I thought it would be interesting to just one of the "quality" report card schemes: Healthgrades.com, which advertises itself as "the leading destination for consumers researching physicians and hospitals online, with 3 million consumers searching the HealthGrades Web site each month."

But I was stopped in my tracks when I read the Healthgrades "User Agreement" which states:

"HealthGrades is not a referral service and does not recommend or endorse any particular Healthcare Provider (emphasis mine). Rather, HealthGrades is only an intermediary that provides selected information about Healthcare Providers. We do not offer advice regarding the quality or suitability of any particular Healthcare Provider for specific treatments or health conditions, and no information on this Site should be construed as health advice. The Healthcare Provider rating information consists of statements of opinion and not statements of fact or recommendations to utilize the services of any specific Healthcare Provider. You should obtain any additional information necessary to make an informed decision prior to utilizing any specific Healthcare Provider."

And yet, look at the trademarked names of their report cards:

"GUIDING AMERICA TO BETTER HEALTHCARE®, THE HEALTHCARE RATING EXPERTS®, THE HEALTHCARE QUALITY EXPERTS®, PATIENT-PROVIDER GATEWAY™, DISTINGUISHED HOSPITAL AWARD™, DISTINGUISHED HOSPITAL AWARD FOR CLINICAL EXCELLENCE™, DISTINGUISHED HOSPITAL AWARD FOR PATIENT SAFETY™, SPECIALTY EXCELLENCE AWARD™, HOSPITAL REPORT CARDS™, PHYSICIAN REPORT CARDS™, NURSING HOME REPORT CARDS™, HOME HEALTH REPORT CARDS™, HOSPITAL QUALITY GUIDE™, PHYSICIAN QUALITY GUIDE™, NURSING HOME QUALITY GUIDE™, HOME HEALTH QUALITY GUIDE™, QUALITY RATINGS SUITE™, COMPAREYOURCARE™, and SMARTCHOICE™"

Hmmm. Seems they're "offering advice" as to who's an "expert," or making assessments as to who's "excellent" in their chosen profession, eh? How can this be construed as anything BUT a "referral service," especially when they advertise their ability to direct traffic to your practice "Internet Patient Acquisition" service or their PATIENT-PROVIDER GATEWAY™? (All for a price, of course.)

Unfortunately, there is no responsibility for the reliability of data:

(Again, from their "User Agreement) "Some of the Site Materials, including but not limited to, certain healthcare information, product reviews, news, data, research, analysis and opinions, are provided by IIPs. As a general matter, we believe that the IIPs obtain such information, materials and other content from sources that they deem to be reliable. However, we make no representations with respect to, nor do we guarantee or endorse the availability, accuracy, reliability, completeness, currency, quality, performance, suitability, or correct sequencing of any information, materials or other content provided by any of the IIPs. We do not endorse, oppose or edit any opinion or analysis expressed by any of the IIPs. We assume no responsibility or liability for any information, materials or other content provided by any of the IIPs.

And yet hospitals and patients, it seems, clamour for this unreliable, unsubstantiated data and assume they're getting "quality" themselves, when the data are anything but.

-Wes

Where to Cut?

(Click to enlarge)

Here's the hospital bill from a relative who recently underwent spinal fusion surgery from one of our local hospitals. The person was in the hospital two days. I found it illustrative for several reasons:

(1) Its itemization was remarkably vague.
(2) It showed what hospitals are billing insurers for surgical procedures these days.
(3) It demonstrates where "costs" can be padded that help pay for other expenses incurred by hospitals.

If you were a money manager or policy maker responsible to cut healthcare costs, which line item in the above bill would seem like the most efficient place to cut costs?

I guess it's better not to think about this and just cut doctors' Medicare reimbursements another 10% or so this June.

Sad how the Leapfrog Group and AdvaMed, two large hospital and business (read: medical device business) consortiums, seem to keep harping on patient safety, pay for performance, and medical error reduction as ways to save costs, while not looking at the grotesqueness of their own partnership arrangements in the continuation of sky-rocketing healthcare costs.

-Wes

Part III: The Opportunity

“If you change a patient’s appointment don’t forget to enter a reason why in the comment field. Do you know, is he a H.M.O., P.P.O. or P.O.S.?”

“Probably a P.O.S.” I thought, chuckling as I kept the double entendre to myself. With that, the receptionist looked up.

“Hi, may I help you?”

“Yes, I’m here for my 2:45 appointment.”

She looked at her computer screen again.

“Fisher?”

“Yes.”

“Bad weather out there today, huh? Did you hurt yourself shoveling?”

“Sure did. I’ll bet you’re seeing lots of people for that, huh?”

“You’re the first today,” she said matter-of-factly as if to want to make me feel even older. “Here are a few forms I’d like you to fill out. Would you like to sit down?”

“Uh, I’m sorry. It feels better if I keep standing right now.”

I looked at the clipboard she handed me. Six pages of fine print paperwork: one page for demographic information like my name, address, date of birth, insurer and so on and, what, my social security number? Hmm. I wonder what bank accounts they could open with all of this information? The opposite side of the page for brief background medical history – all meant to reassure that someone actually looks at this stuff, but more likely to entrap me for possible insurance fraud if I should lie or forget something, I thought.

The next four pages were ludicrous examples of the follies of bureaucracy: a “Privacy Statement” (2 pages) and explanation of the Health Insurance Portability and Accountability Act (HIPAA) and what it means to me – carefully juxtaposed to the pages containing my entire life and medical history, social security number, date of birth, etc. Bureaucracy to Content ratio: 3 to 1. What a waste, I thought. Pages and pages of text were provided just to explain an obscure and effectively meaningless document to the average Joe, just so my information can whir about cyberspace with nary a liability concern to the Great Third Party.

I stood in agony as I completed the forms; most of which had nothing to do with facilitating my care.

Rather, it was all about jostling for the few dollars afforded by my insurer because in the eyes of the rehab facility and our health care system, I had become an opportunity to collect.

And as I looked down to replace my insurance card back in my wallet, I saw it. Up in the upper right-hand corner of the card. Like a piece of beef and in bold letters for all to see:

"Plan Option 3 - Choice P.O.S."

-Wes

Part II: Access

I sat and pondered my predicament. Acute lower back pain – hardly able to move – clinic all day, three cases tomorrow, call this weekend. Ennie meenie miney moe.

I called my secretary. “Peggy, I know this is last minute, but I pulled my back and can barely move. Could you look at my schedule and see if we could rearrange things so I could be seen this afternoon. I suppose I could see the first two new patients this morning – but then I’m really going to have to work on this back thing…”

“Oh honey, just take the day off – you couldn’t help it,” the Mrs says in the background.

“Oh, I bet a lot of your patients won’t mind not fighting the snow today, Dr Wes – I’m sure I can reschedule them. Are you sure you can make it in?”

“Sure, Peg, the Mrs will drive me.” I say smiling at my wife who has flames in her eyes.

“I want to you to call right away and get an appointment with a physical therapist,” the ever-reasoned Mrs says.

I hestitated. “How the hell do I do that? I mean, I’d have to call my doctor for a referral. You mean a doctor might have to see a doctor? Never!” I thought.

The look at me told me I’d better reconsider. So I dialed the phone – not knowing my doctor’s office number, I did what any self-respecting doctor should do – I called the hospital operator.

“Hello, this is Dr. Fisher, could you connect me with Dr. Smith’s office?”

“Uh, how do you spell that?” said the soft-spoken voice from the hospital.

“S-M-I-T-H.”

“Just one moment, please.” And I was placed on hold. I heard the hospital marketing jingle playing in the background – it was the lyrics from Joe Crocker:

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.

I couldn’t help but smile. Just then a timid-sounding individual picked up the phone. “Hello, Dr. Smith’s office, may I help you?”

“Yes, this is Dr. Fisher, could I speak with Dr. Smith?”

“One moment please.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.

“I’m sorry, Dr. Smith isn’t in yet. He is seeing patients today but he’s delayed by the snow.”

“Could you tell him I called regarding a referral.”

“Sure. What’s your number? “

“312-555-xxxx”

“I’ll make sure he gets the message.”

I proceed to see my now-limited clinic. Funny hobbling in to see them; my problem seemed so trivial compared to theirs. True to form, my patients were remarkably empathetic to my situation. Damn they were nice. But I was glad I persevered: one had to have his procedure tomorrow due to a series of serious circumstances. Now I'm up to four cases tomorrow, I thought. So I finished, completed the all-important electronic paperwork, and headed home. I tried calling my doctor again to see if I could get that referral – I hadn’t heard back yet. Probably busy, I thought.

“Hello, Dr. Smith’s office, how may I help you?”

“Yes this is Dr. Fisher. Could I speak with Dr. Smith please?”

“Is it about a patient?”

I hesitated. Hmmm. How to answer? I might get a faster response if I just ask to speak with him a moment, but then, I guess I am a patient right now.

“Yes.”

“And what’s their name?”

“Uh, it’s me, Dr. Wes.”

“And your date of birth?”

I gave it to them.

“Just a moment please.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.

I waited.

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.

A new voice picks up. “Whom are you waiting for?”

“Dr. Smith.”

“Just a moment.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.

The new voice: “I’m sorry, Dr. Smith is in seeing patients. Could I get your name and number so I can have him return your call when he’s free?”

I gave it to them. Home and cell numbers. I knew this wasn’t an emergency and I thought I should try to play by the “rules.” So I succumbed.

“When can I expect a call?”

“Between patients.”

“Thank you.”

I was beginning to feel a bit concerned that the day was withering away and I still had no rehab appointment for the afternoon. The Mrs suggested I call a rehab facility myself. I did. They could squeeze me in this afternoon, but would need a referral and my insurance card. I felt relieved. At least I could get seen today, but it would require that I make another attempt at reaching my doctor. Oh, God.

So I waited until about an hour before the appointment to permit time for a return call – sadly, none came. So I called again. I wasn’t “feelin’ so good myself” at this point.

“Hello, Dr. Smith’s office, how may I help you?”

“Yes this is Dr. Fisher. Could I speak with Dr. Smith please?”

“Is it about a patient?”

“Yes. This is about me. It is also the third call I’ve made to this office. Is doctor Smith available?”

“Just a moment please.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.

“I’m sorry, Dr. Smith is in with patients right now.”

Well-trained I thought, but no match. I get it now.

“I’m sorry, but I want to talk with his nurse, office manager or the doctor and do not want to hang up again. This is my third call and I need a referral before 2:45 today.”

“Just a moment.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.

“Hello, this is Ms. Office Manager. Can I help you?”

I explained by situation.

“I’m sorry, Dr. Fisher. Just a moment.”

You feeling alright?
I'm not feeling too good myself, no
Yessir, you feeling alright?
I'm not feeling that good myself, no.

“I’m not sure what’s happened, but I can’t see a record of your prior calls.”

Okay, I’m a professional. I tried to keep my anger contained. I realized I should not shoot the messenger, but boy, did I want to. Just before lunging through the phone, she continued:

“But I’ll handle this for you. I’m very sorry about your inconvenience. I checked again and Dr. Smith is still with a patient. But I’ll make sure it happens. My name is Ms. Office Manager.”

“You’re sure.”

“Yes, quite sure.”

“And you’ve entered this call on your phone log and have my name, SSN, date of birth, name of my first born, name and fax number of the rehab facility, etc., etc.”

“Yes.”

‘And it’ll be handled?”

“Yes.”

And thankfully, it was.

But the experience taught me a lot about our health care system of today. I know my doctor is a good guy. Part of this was my fault – I see him too infrequently – and I called him out of the blue for an acute problem.

But access to primary care really is a huge systemic problem. In our efforts to preserve sanity of primary care doctors with ever-increasing patient-care loads, we have created systems to permit doctors to work as efficiently as possible given the demands on their time. Specific well-intentioned shields have been erected to avoid inefficient distractions like acute medical illnesses. Phone message pools, answering systems, difficulty speaking directly with the doctor or even the nurse – all make for a horrible patient experience as we try to triage the work efficiently. Yet none really triage the problem at hand. Instead we get the obligatory "if-you-think-this-is-an-emergency-hang-up-and-dial-911" message. The inadequacy of this approach either leads to a loss of a referral by way of Walmart, a Minute Clinic, or the Emergency Room at best, or perhaps an injured patient with a more severe problem at worse.

I was lucky. I acted proactively because I know and work in this system. Importantly, I also came to realize that my own direct access is equally guarded – in part because I am often in procedures and yet more to the point – phone calls are time syncs – and time is money. So I have a nurse practioner help with these tasks.

While Medicare now reimburses some for phone calls made by physicians regarding outpatient services, they still do not pay for any calls following procedures – calls that could probably save tons of money if attended to promptly. But bureaucrats don’t see this. They see this time as covered under their 90-day post-operative “global period” – a ridiculous assumption that every ounce of effort for follow-up care to assure an expected outcome has already been paid for – and then they have the balls to reduce that fee by some 18% as of 1 January this year through trickery of billing rules.

I can't wait until BillaryCare is implemented. If we think this sucks now, we ain't seen nothin' yet. By flooding more patients into our system without addressing the shortage of capable front-line doctors, it's going to get ugly.

-Wes

Addendum via a reader tip: "Feelin' Alright" was written by Dave Mason of the band Traffic. Joe Crocker performed this as a cover song. I regret the error.

Part I: Metamorphosis

It started innocently enough: a big Chicago snow storm followed by a period of relative warmth and rain, followed by the usual repeat of another anticipated eight inches of snow. Typical Chicago weather.

And I, being of unusual vim and vigor, set out to shovel the walk before work at the request of the Mrs. After all, 8 more inches on top of the slushy mix were to make for a hazardous path upon which to walk.

It was really heavy stuff. Not the usual fluffy white stuff. But the slushy/watery mixture was quickly moved off the walk since this had set back my usual before-work timing yesterday. I stood triumphant.

But there were a few last remnants of snow and slush that looked like they might represent a hazard. So I took one last past to clean those up, lifted the shovel only half-full of snow and, BLAM, a sudden piano-wire of sorts ruptured. I have no clue what it was, but there, standing on the sidewalk I was paralyzed with pain. It was like a 6,000 volt power line had attached to my lower back and sent it into uncontrollable spasm. I grabbed the nearby fence with my left hand and held the shovel handle with my right hand – not sure what to do next. Standing straight was not an option. Nor was twisting at all. My physician self thought: “Okay, I can still feel my legs. No real weakness. No radiculopathy. You should be okay. So walk.” Shuffling like a 90-year old with a walker in a torrential snow storm, I hobbled back to the house. Damn my back hurt.

I managed to get back to the house and first tried to lie on the floor.

Bad idea. I soon found that any attempts to right myself were met with remarkable spasms of pain. I could find a relatively comfortable position, but soon realized I could not lie there all day. So I log-rolled, flexed my knees just enough to rise to my hands and knees, then groveled back to a chair to plan my next move. Meanwhile, my back was still sending paroxysms of neuronal afferents to my cortex gleefully. Little bastards.

Now what? There I was, one hour before a full day of clinic was to start wondering what the heck do I do now? I mean what kind of idiot would do this to himself? Three surgeries tomorrow, weekend call this weekend. Back hurts like hell. And I’m unable to move except with remarkable discomfort. I have to get to clinic, I thought. My patients are probably already there.

My mind scrambled. I contemplated my next moves. I called my secretary to discuss the situation: perhaps reschedule folks? Have a colleague cover? Grin and bear it?

And then it dawned on me really why this was so terrifying:

A doctor had just become a patient and had to learn to negotiate their side of the health care system.

-Wes

Operating Room Attire

Today's scrubs. We'll see what the Sanitation Sandanistas think about my bling.

-Wes

Isn't It Ironic?

...that on this eve of the Super Tuesday primaries, healthcare and the mandates that Senator Hillary Clinton is proposing to fund her proposal (supported by the monstrous legal lobby behind her), might be her undoing again?

I mean, garnishing wages to feed insurers?

Well, at least she's telling it like she sees it. David Catron of the blog Health Care BS frames the problems for Sen. Clinton from a national (and yes, more conservative) viewpoint clearly.

-Wes

Great Game

The Superbowl exceeded by expectations this year - Jordin Sparks did a nice job with the Star Spangled Banner, Tom Petty and the Heartbreakers were pretty good at the halftime show that lacked the usual Superbowl schlock of prior years, some great football and amazing defense of the Giants that lead to their unexpected HUGE upset - with suspense that lasted to the last few minutes of the game. It doesn't get much better than that.

The ads, however, were mediocre, for the most part. But fortunately, there were only two drug ads: both OTC meds - Zantac (appropriately placed right after halftime) and Claritin antihistamine. Gosh, only $5.4 million spent - really, remarkable restraint was demonstrated by the pharmaceutical industry. It is interesting that these two ads did not appear on the MySpace webpage summarizing all of the ads shown - wonder why?

But there was one ad in particular that caught my cardiologist's eye:




The little legs that sprouted from the heart were cute, but I'm still trying to figure out how she stays conscious after her heart leaps from her chest...

... maybe she had a LVAD installed first ...

-Wes

Pacemakers and iPods Revisited

Finally, another study confirms the safety of iPods and pacemakers.

For this study, Bassen tested a second-generation iPod Nano, a second-generation iPod shuffle, a fifth-generation iPod Video with a 30-gigabyte hard drive, and a standard iPod with a 15-gigabyte hard drive and dock connector.


For all of them, data taken at 0.5 and 1.0 cm from the case showed a field of 0.2 micro-Tesla or less, with a highly localized 100 kilohertz sinusoidal signal.


The fields existed only in an area of about 1 cm2 and were not measurable at distances greater then 1 cm from the case, Bassen said.


He also found no measurable fields near the earphone cable, except at the earphone itself.

Hopefully, the American Heart Association will pick up on this story and print a retraction to their earlier fear-mongering quiz.

-Wes

h/t: MedPage Today.

Medtronic's Endeavor Stent Finally Approved

As expected, Medtronic's Endeavor drug-eluting stent was approved by the FDA today.

Looks like more competition has just arrived for this crowded space.

-Wes

Doctors in the Democratic Debate

I watched the democratic debate last evening for evidence that there was a tangible way healthcare reform could take place. I failed to hear anything about "doctors" mentioned much.

So I used the New York Times handy-dandy transcript analyzer and found that the word "doctor" was uttered just twice in last night's democratic debate, once by Senator Clinton and once by Senator Obama. "Nurse" or "physician" were never uttered.

Here were their words:

SEN. CLINTON: "And then, when the celebrations are over, the next president will walk into the Oval Office. And waiting there will be a stack of problems, problems inherited from a failed administration -- a war to end in Iraq and a war to resolve in Afghanistan, an economy that is not working for the vast majority of Americans, but well for the wealthy and the well-connected; tens of millions of people either without health insurance at all or with insurance that doesn't amount to much, because it won't pay what your doctor or your hospital need -- (applause) -- an energy crisis that we fail to act on at our peril; global warming, which the United States must lead in trying to contend with and reverse; and then all of the problems that we know about and the ones we can't yet predict."

SEN. OBAMA: "But understand that number one, Hillary says that she's got enough subsidies.

Well, we've priced out both our plan and Senator Clinton's plan, and some of the subsidies are not going to be sufficient, point number one.

Point number two is that I am actually not interested in just capping premiums. I want to lower premiums by about an average of $2,500 per family, per year, because people right now cannot afford it. I can't tell you how many folks I meet who have premiums that are so high that essentially they don't have health insurance. They have house insurance. (Scattered applause.)

What they do is they have a $10,000 deductible or what have you to try to reduce costs. They never go to a doctor. And that ended up something that we paid for. So I'm trying to reduce premiums for all families.

But the last point I want to make has to do with how we're going to actually get this plan done. You know, Ted Kennedy said that he is confident that we will get universal health care with me as president, and he's been working on it longer than I think about -- than anybody. But he's gone through 12 of these plans, and each time they have failed.

And part of the reason I think that they have failed is we have not been able to bring Democrats, Republicans together to get it done."

Maybe the fact that doctors and nurses are rarely mentioned has something to do with why there have been so many failures of healthcare reform before.

-Wes

Reference: The full debate transcript can be found here.

Update 13:00 CST - In the spirit of bipartisanship, I also reviewed the most recent Republican presidential debate transcript from Florida and "doctor," "physician," or "nurse" were never uttered there, not even once.

Imaging Turf Wars

Well the inaugural issue of JACC Cardiovascular Imaging was just come out and heralds cardiologists as cardiovascular imaging experts. Eugene Braunwald's welcome letter was telling:

"Despite its great advantages, selective angiography is an invasive technique that may be uncomfortable, entails some minimal risk to the patient, and is expensive. It can be applied only a limited number of times in each patient and it is not suitable for screening. Therefore, physicians caring for patients with known or suspected heart disease yearned for noninvasive cardiac imaging. Fortunately, 2 new techniques—echocardiography and nuclear imaging—became available in the 1960s and have improved progressively since then. Literally tens of millions of these examinations are performed each year, transforming medical practice. In the 1980s, 3 new noninvasive imaging techniques—computed tomography (CT), cardiac magnetic resonance (CMR) imaging, and positron emission tomography (PET, a nuclear technique)—emerged. Each of these provides information on cardiac structure and function that is an order of magnitude greater than the earlier imaging techniques.

None of the aforementioned techniques are static and all are undergoing progressive refinement. Many important advances have been made by subspecialists in a single technique such as echocardiographers, nuclear cardiologists, and specialists in CT, CMR, or PET imaging, respectively. Each of these imaging modalities have their individual training programs, and the advances in these fields are described in specialized journals, each devoted to a single technique. Although this approach has been responsible for spectacular advances in each modality, it has led to fragmentation of patient evaluation, at times to competition between individual modalities, and to increased costs at a time of diminishing resources to pay for health care.

There is a growing consensus that the time has come to consider cardiovascular imaging in a more comprehensive, unified manner. We need a new generation of cardiac imagers who are expert with the entire portfolio of modalities and who can provide a nonbiased selection of the technique that can best solve the clinical or research problem at hand. To develop these broadly-based experts, we need new unified training programs that break down what are sometimes artificial interdepartmental and intradepartmental barriers.

Another important tool in shifting the imaging paradigm is to develop a journal of cardiovascular imaging. The Publications Committee of the American College of Cardiology and its talented staff, working closely with the College leadership, developed a vision for and then the concrete plans for the creation of JACC: Cardiovascular Imaging. The committee and its consultants selected the Editor-in-Chief, Dr. Jagat Narula, from a group of distinguished cardiac imagers. Dr. Narula has put together an outstanding group of associate editors, editorial board members, and consultants. They now deserve the cooperation of the entire cardiovascular community as they proceed on their important mission."

Radiologists are none too happy, I'm sure. No doubt they might take issue with the claim of "We need a new generation of cardiac imagers who are expert with the entire portfolio of modalities and who can provide a nonbiased selection of the technique that can best solve the clinical or research problem at hand." The friendly collaboration between radiologists and cardiologists went out the window long ago.

Why?

It's all about the money.

-Wes