EKG DU Jour #19: A Case of Obtundation

A 60 year-old man was found obtunded, unable to ambulate or communicate at home by a house cleaning service. He was brought to the emergency room and found to by hypotensive, bradycardic and was intubated emergently due to poor ventillatory effort. His initial potassium was found to be 7.6 meq/L and a slow junctional escape rhythm of 40 b/min. He was administered calcium, insulin and glucose, and the EKG, shown below, improved a bit.

Click image to enlarge

An astute observer glanced at the EKG and posed an important question to the ER staff.

What was the question?

-Wes

Addendum 18:45 CST - The EKG image was updated to permit better enlarged viewing.

Text Paging Health Information

I saw this in a recent nursing note:

Urine noted to be bloody without clots.
Text message sent to 2290 (trauma pager) about hematuria.
Patient denies any pain at this time.

No doubt patient identification or their room number, was sent to identify the patient (I'm not sure which). I suppose a record of the physician covering the trauma service that night is discoverable.

But I wonder, in the world of cyberspace with electronic communication carrying such an important role in health care delivery lately, is HIPAA really enforceable or will it just be used to extract huge fines from care providers now that the new HITECH policy expands HIPAA's reach.

Since text pages are neither encoded nor retained as an official audit trail of care delivered, it seems to me care providers are vulnerable, even when they are doing the right thing for the patient.

-Wes

Primary Care's Problem: Putting the Sexy Back

Hugh Laurie can't do it. (We need to cut back on over testing, doctor, and those pills!...)

Marcus Welby can't do it. (Who? You mean that OLD guy?)

8% pay raise through cost shifting can't do it. (And you want me to fill out how many forms?...)

Calling their clinic a "medical home" and flooding it with angry people who can't get an appointment won't do it.

So how do you do it?

How does one go about putting the "sexy" back in primary care?

This is one of health care reform's biggest problems and right now, just about every piece of legislation promised to further overwhelm primary care doctors with more hoop-jumping than ever before. From ICD-10 with it's 150,000 billing codes, to mandates to purchase expensive medical record systems that, so far, have proven their worth to administrative collection agents in their protected silos well before they have proven their worth to our nation's health. Or to pay for performance, a form of least-common-denominator medicine that forces compliance before enabling innovation in health care efficiency. Primary care is no longer sexy, it's becoming cookbook. So much so that nurse coordinators have become the new buzzword for primary care - not exactly a reason to enter four long years of medical school and three more years of residency training. Who wants to go to school of become a doctor only to find out that you're really going to school to become a nurse manager?

And then there's the academic mega-centers' disdain for private practice care. The not-so-subtle elitist attitude that private doctors in the community aren't nearly as good as the academic megacenters' specialist care, while they, themselves, have never set foot outside their pearly gates to work in the trenches lest their white coat become soiled.

Primary care is not about medical robots, waterfall lobbies, big screen TV's and marble floors. But those things are sexy. And we all know that Americans, like bugs, are drawn to bright and shiny objects. We love the whizbang, the big buildings, the nice decor. We scream for the latest and greatest hospital additions with computer technology and the latest robots, only to turn around the next day to scream about our hospital bills. God forbid we put two and two together.

Primary care doctors are up against all of this and the marketing efforts they employ. No wonder they cannot compete.

Putting the sexy back in primary care will involve anything but more bureaucracy and oversight. Congress does not get that these aren't sexy. To them, the tombs of legislation are what's sexy ("See all the work we did?")

But what's sexy to doctors is using independence and entrepreneurism in medicine for the patient's benefit. That's sexy.

And unless our legislators get that, primary care will go the way of the dinosaurs and the great paucity of care providers imposed by bureaucratic doctrine, will continue unabated.

-Wes

Addendum: Today we find that general surgeons are way ahead of primary care doctors in bringing sexy back to their profession.

It seems some are leaving the drab of emergency room call to fill SWAT teams in a "national movement" to embed medical professionals "so that help is at the ready should something go wrong."

Pitty the poor ER patient who finds the general surgeon is out on a drug bust.

US Health Care Reform Photoshop Contest on Its Final Stretch

Just a reminder: there's a little over 24 hours left to submit your entries to the US Health Care Reform Photoshop Contest where a single tastefully doctored photograph that summates your feelings about the health care reform efforts underway could win you an Apple iTouch. Entries are due by 11:59 PM CST and should be e-mailed to wes - at - medtees - dot - com. Full contest rules can be found here.

Good luck!

-Wes

When a Nurse Contracts Malaria

In 2008, Dawn Dubsky was a nurse at Children's Hospital in Chicago when she took a trip to Ghana, where she contracted malaria and all its complications. In a two part series, the Chicago Tribune chronicles her story. The results, in many ways, were profound:



-Wes

Putting the "Happy" in Thanksgiving

Who said hospitals can't have fun? Provident St. Vincent Medical Center, Oregon shows us how as they support breast cancer awareness:



Only one question: where were the adminstators?

Happy Thanksgiving!

-Wes

Some Thoughts for Thanksgiving

I thought I'd share this list that was published on this blog before:

I am thankful for the teenagers who are complaining about doing chores -- that means they are home and safe.

... for homework. It means we live in a country where education is valued and encouraged for all.

... for the taxes I pay; it means I have income.

... for the mess that I have to clean up after parties, because it means I am surrounded by friends.

... for the clothes that fit a little 'too snug' because it means I have enough to eat.

... for the lawn to mow, windows to wash and gutters to clean; it means I have a home.

... for the parking spot I found at the far end of the parking lot, because it means I am capable of walking and am blessed with transportation.

... for my huge heating bill, because it means I am warm.

... for the person behind me in church that sings off key, because it means I can hear.

... for the pile of laundry and ironing, because it means I have clothes to wear.

... for all the complaining I hear about the government; it means we have freedom of speech.

... for the alarm that goes off early in the morning because it means that I am alive!

Author unknown

And one other thought: be sure to visit Paul F. Levy's blog, Running a Hospital, to learn about the Engage With Grace program to how you can engage in a conversation with your loved ones about their (and your) end of life wishes.

Now, especially, is a good time to reflect on what we can do for others.

-Wes

When Insurers Dominate Market Share

Prices rise:

One factor that could be driving larger increases locally: Blue Cross & Blue Shield of Illinois, which historically has used its dominant 50%-plus marketshare to undercut competitors' prices, has been more aggressive with rates this enrollment season, brokers say.

"Blue Cross is the one company that is consistently coming in with higher renewal increases," says Rob Wilson, an insurance broker and president of Westmont-based Employco Group.

A Blue Cross spokeswoman declines to comment.

Funny that when hospital systems coalesce and raise prices to remain "competetive," the FTC cries foul, but when the insurance industry does the same thing, the FTC can't be bothered.

But then, the government knows what's best for patients, right?

-Wes

Code Blue, Then and Now

Then:

11:30 pm - Cackling though the overhead intercom system:
“Code Blue, Three East, Room 236”

A thunderous herd of medical students, residents, anesthesiologists, cardiologists, social workers, security personnel descend on the scene. Arriving, the chief resident is in charge at the foot of the bed. IV’s have been started, some young well-muscled individual is bobbing up and down on the unseen’s chest, brow glistening with sweat, but focused. An anesthesiologist, noting the agonal rhythm, works to secure the airway, then a central line. Nurses administer drugs, bring line kits. Airway secured. “EKG? Where’s the EKG?” Electrode replaced. “Story? Who’s got the story?” Ten. Twenty. Thirty. The minutes pass. Finally, silence, as the monitors removed and the group departs. Like sound and fury, signifying nothing.

Now:

11:30 pm – The pager sounds:
* bleep bleep bleep *
A digital image appears on the screen: CODE BLUE, Room 2001

I was not on call, but I wondered, “Was this a patient of mine?” “Did I forget someone?” I raised my head from the pillow and strolled in to the accompanying room where my outdated computer sat and waited while it booted. “What might have happened?” “Is it someone old or young?” Thoughts spun just as the disk drive. Waiting. I typed by keyfob’s codes, I entered by password twice, I waited some more then the electronic medical record appeared and I checked the name next to the room number. For the first time, the number meant something: a person, 88 yrs old, yet someone I did not know. The scene appeared from miles away.

I sat back and perused the chart. Heart attack, conservative management, hypotension, fluid bolus given, then nothing more.

A few more keystrokes and the computer went black.

Then sleep came poorly once again.

-Wes

Want To Opt Out of Medicare?

Here's how, courtesy of Mayo Clinic Family Medicine - Arrowhead (Arizona):

The discrepancy between what Medicare pays and our cost of providing care acutely impacts the sustainability of our primary care practice. Medicare reimbursements do not cover our actual costs of providing care, and therefore we have recently had to make some difficult decisions that will impact the Arrowhead Family Medicine practice. Effective January 1, 2010, the physicians at Mayo Clinic Family Medicine - Arrowhead will opt out of participating in Medicare, meaning that Medicare will no longer reimburse for the services they provide....

With the $500 billion dollars of cuts to Medicare spending in the new health care bills proposed, will we see more of this in more affluent areas?

-Wes

Early Health Care Reform Photoshop Entries Are Up

Early US Health Care Reform Photoshop Contest entries are available to view here. (I did the one at left - sorry, it's ineligible). There's still plenty of time to submit your entry. Entries will be still be accepted until 30 Nov 2009 at 23:59 pm CST!

-Wes

As Hospitals Gain Cardiologist Employees, Private Cardiologists Are Shunned

An interesting story has developed in Missouri where a private group of cardiologists was asked to no longer see their patients at the local hospital. It seems the hospital hired it's own group of cardiologist-employees. Things grew so contentious according to the video accompanying the report, when the cardiologists asked for an OR lite, they were told to use a flashlight (the hospital disputes the claim).

As the cardiologist shift to adjust for the economic realities that confront them, they have much more to lose from their patient relationships as its the patients that are inevitably affected the most when these shifts occur.

-Wes

Sebelius: Talking the Talk or Walking the Walk?

Here's a bit of the transcript from Kathleen Sebelius, Department of Health and Human Services Secretary, speaking to the Wall Street Journal's CEO Council (approximately 2 min, 45 sec into video) about saving health care costs:

... There are lots of features of the House Bill and that are already in the Senate bill that change that (the way doctors are paid). We are beginning to move away, particularly in Medicare, from traditional fee-for-service pay that I would suggest not only causes redundancy but doesn’t encourage innovative, high quality, low cost practices to moving toward a system that exists in pockets, exists in Mayos, Geisinger, (Inter-)Mountain Health Care. We know what it looks like. It isn’t how medicine is practiced it isn’t the the hospitals and providers are paid, so "bundled payments," "medical care homes," "accountable care organizations" – all buzzwords for really providing financial incentives and eventually financial penalties for appropriate medical protocols and appropriate outcomes - stopping the system now where one out of every five who’s released from the hospital is back in 30 days having never seen a health care provider, reducing or eliminating hospital-based infections, which are now one of the top 10 leading causes of death in America. We know exactly the system that can be done to stop it. It doesn’t take any capital investment It doesn’t require any new technology.”

I wonder what she means by "... eventually financial penalties for appropriate medical protocols and appropriate outcomes?"

Why penalize people for adhering to appropriate medical protocols? Or maybe she just needs some sleep...

And then there's this quick fact check:

Septicemia: #10 in 2006 (1.3% of deaths) CDC list for death in America and was #11 in 2004 (1.4%) but is substantially better than rates in 1997 (2.4% of deaths).

(Just keeping it real.)

-Wes

Medical Bloggers' Grand Rounds Is Up

... this week over at Colorado Health Insurance Insider.

-Wes

Compensating Doctors for After-Hours Call Coverage

Should there be a premium added to physician compensation for on-call coverage after hours, or are Medicare rates enough?

This appears to be the central question between two competing hospitals in Longview, Texas where a $300,000 stipend was paid to a cardiology group by one hospital and not the other for cardiology on-call coverage.

Guess which one the doctors are promoting now?

Banos said the Diagnostic Clinic cardiologists recently approached Good Shepherd "demanding hundreds of thousands of dollars in compensation from Good Shepherd for providing call coverage to the patients of Good Shepherd."

"This is in addition to whatever money they are able to bill and collect from patients and their insurance companies for the services they actually provide when they are called in to perform a procedure," Banos said in his e-mail to Good Shepherd employees.

Banos said he believes the demands for compensation were "veiled threats to move their elective procedures to Longview Regional if we did not pay." He added Good Shepherd's stand is that meeting the compensation demands would "not be fair to the many other physicians on our medical staff who selflessly and without any expectation of pay [from the hospital] provide call coverage to our patients each day as part of their commitment to the community."

"We cannot meet the needs of our community and pay doctors for doing something that they are already obligated to do as a part of their community obligation" Banos said.

Banos said he believes Longview Regional agreed to pay the cardiologists more than $300,000 a year for on-call coverage.

"We do not believe that it was by chance that it was only after this agreement was reached that these physicians touted Regional's 'commitment to quality care' and announced their 'choice' of Longview Regional for their patients." Banos said. "We knew that taking a stand could result in these physicians moving their elective cases to Longview Regional, and it did."

Before condoning the cardiology groups' actions strictly on the basis of greed, we should note that there is a precedent for higher pay for employees working after hours in industry. Hospitals, too, have resorted to paying "nocturnists" (night-shift hospitalists) higher salaries than their daytime hospitalist counterparts as they struggle to find staff willing to work the night shift managing inpatients. These salaries are not covered strictly by funds received from the paltry Evaluation and Management payments paid by Medicare, rather, they are subsidized by the hospital system.

Threatened with unprecedented pay cuts from Medicare, look for this trend to continue as doctors use their only remaining asset, patient referral clout, to negotiate their compensation going forward.

-Wes

How Not to Consent a Patient for Angioplasty

Yikes!

"Honey, all you need to worry about is if I am going to listen to opera or Steely Dan during the procedure."

-Wes

P.S. I told you "Honey" was bad.

US Health Care Reform Photoshop Entries

Last updated 24 NOV 2009 @ 06:00 AM.

Early entries for the US Health Care Reform Photoshop Contest are shown below in the order they were received. Remember, the deadline for entries is 11:59 CST 30 Nov 2009. This post will be updated from time to time as new entries arrive.

(Editor's note: We're putting the entries up as they're sent. Remember, you'll ultimately be the judge.)

1) "Health Care Cat" (in the spirit of LOLCats):



2) "Gonnorrhea for Rationed Health Care"



3) "Healthcare Budget":



4) "Taking Care of the Healthcare Pest":

US Health Care Reform Photoshop Contest

In the spirit of the upcoming holiday season and to make sure something on health care reform gets done before the end of the year, Dr. Wes and his wife, Diane, would like to propose the first (and perhaps only) US Healthcare Reform Photoshop Contest.

Bring us your snark, your wit, your creativity about the health care reform efforts encapsulated in a single photograph. Photographs in support or against the current efforts will be equally considered, and you, dear internet devotees, will be the final judge. The winner receives an iPod Touch.


Rules: No more than one photo entry per household, please. Create a single photo using Photoshop or other equivalent photo-editing software that encapsulates the essence of health care reform as you see it. Photographs must be G, PG, or PG-13 rated and family-friendly (R or X-rated photographs will be enjoyed, but not eligible or posted). An example image we created is shown above. Please do NOT use copyrighted photos.

E-mail your entries to me at wes - at - medtees dot com (please keep file sizes under 100K) with your name, address and e-mail contact information and I'll post the vetted entries on a webpage on this blog in the order they are received. If the response is overwhelming, we reserve the right to limiting the images posted to our discretion.

Depending on the number of entries, our highly distinguished referees (my wife and I) will choose the five or six photographs that will serve as the finalists by no later than 11:59 PM on 30 November 2009. On 2 December 2009 or so, the chosen finalists will be displayed and the polls will open for you to choose the winner. The photograph with the most votes tallied will receive an 8Meg iPod Touch. Voting on the finalists will close 11 Dec 2009 at 11:59 PM. This way, we hope there's plenty of time for our prize to reach the winner before the holidays and final health care reform vote. In the unusual event there is a tied vote, we will chose the winner between the two favorites.

So get going, be creative and most of all, have fun!

Happy holidays!

- Wes and Diane

P.S.: Please spread the word!

FTC Disclaimer: No advertising sponsors are supporting this contest.

Addendum:

If you'd like to help promote this contest on your blog by placing this tacky button on your sidebar, just copy the HTML in the textbox below and add it to the your blog's sidebar code:

<a href="http://drwes.blogspot.com/2009/11/us-health-care-reform-photoshop-contest.html"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 120px; height: 120px;" src="http://www.medtees.com/blog/HC_Contest.jpg" border="0" alt="Health Care Reform Photoshop Contest Rules" /></a>

The entries so far can be viewed here.

Problems With Low-Energy External Defibrillators?

Seems the FDA wants to know more:

FDA is investigating energy levels in (automatic) external biphasic defibrillators (AEDs) with shocks ≤ 200 J. FDA has received reports of 14 events since 2006 in which a 200 J biphasic defibrillator was ineffective in providing defibrillation/cardioversion therapy to a patient, whereas a subsequent shock from a different 360 J biphasic defibrillator resulted in immediate defibrillation/cardioversion. The majority of events occurred during attempts at cardioversion of atrial fibrillation, but there was at least one instance with defibrillation of a ventricular arrhythmia as well. FDA is seeking additional information in order to interpret the significance of these events, and to determine whether FDA activities are advised.

I haven't seen this, but others may have, so let 'em know.

-Wes

Waiting, and Hoping, For a Heart

A patient, recently listed for cardiac transplantation, tells his story about being rejected, then accepted, to the cardiac transplantation list:

Next week, I'll check into Mayo, one of the world's premier hospitals, to undergo additional treatment in preparation for receiving a new heart. Since my brain tumor turned out to be benign and my prostate cancer has responded to treatment, doctors there said those issues no longer should disqualify me as a candidate for a heart transplant.

Now that I'm on the list, I am on an around-the-clock standby alert. I have to be ready to be on the operating table within four hours once a compatible heart becomes available. The fact that Chicago is 331 miles from Mayo, in Rochester, Minn., complicates things since I don't have my own charter jet. But the Mayo Med Air charter service could assist me if a commercial flight can't get me there quickly enough.

The challenge now is the wait. The heart I need will become available only when the donor is declared brain-dead and his heart can be taken from him and implanted in me within four hours. I am told the fact my blood type is B positive increases the chances of me getting a transplant quicker, though there are other patients ahead of me.

I had wanted it all to happen at the University of Chicago Medical Center, where world-renowned Dr. Valluvan Jeevanandam, who performed a triple-bypass on me in 2001, has done more than 1,000 transplants. But that hospital takes a more conservative approach to the fact my prostate cancer still is in remission. They wouldn't put me on the transplant list until I had been using an implanted heart pump ''for several years.''

Fortunately, the Mayo Clinic and Northwestern Memorial Hospital feel I have progressed enough in my recovery from the slow-growing prostate cancer to be eligible for a heart now.

With the competetion for patients underway as the large health care system land-grab extends across state lines and overseas (See here and here), have the selection criteria for transplant patients remained a form of rationing or really become a form of marketing?

I wonder.

-Wes

How to Find the Arrhythmia Patient's Room

When it's 1:00 AM and you're not sure where the patient with incessant ventricular tachycardia is located in the ICU, just turn to the telemetry strips:

Click image to enlarge

-Wes

Need a New Medical School?

... just be a holdout on the vote to approve the House health care bill:

In a statement, Costa said he succesfully negotiated funding for a UC Merced medical school.

"I am voting for HR 3962 because the choice of doing nothing was not an option. During my negotiations to help improve the bill for our Valley, I was able to achieve funding for a medical school in the Valley, with studies at UC Merced and residency in Fresno, as well as additional incentives to bring health professionals to our Valley. Increased funding in this bill for programs ranging from nurse training to health career opportunity programs to community health centers and increased reimbursement rates for low-paying Medicaid will go a long way in strengthening our health system in the Valley," Costa said.

The bill, HR 3962, passed the House of Representatives with a vote of 220-215.

Cardoza said the bill directs $167 million in health care funding to hospitals in his 18th district alone. The district includes parts of Fresno and Madera counties. But Cardoza said he still has concerns about the cost of the bill.

I love the last sentence: "... and he still has concerns about the cost of the bill."

Yeah, right. And if you believe that, I've got some oceanfront property in Arizona I'd like to sell you...

-Wes

Frontloading Surgical Performance

I must say, in all the years I have been practicing medicine, I have never seen a "thank you" gift delivered before surgery, but recently, our team got delivered this:

Click image to enlarge

Needless to say, I was floored.

But then I read the note, which was priceless:

Click image to enlarge

Fortunately, all ended well, and no "oops" were had.

But talk about the pressure to perform well!

:)

-Wes

The House Health Care Bill and Bureaucratic Duplication

I don't mind health reform. In fact, I believe we need it. But when reform bills fund projects that already exist, or fund special projects for other non-health care professionals, like lawyers, I have to wonder what Congress is doing.

The recently passed House bill (H.R. 3962 pdf) contains a multitude of grants and "demonstration projects." I wasn't sure what some of these grants were meant to support, so I looked them up. I was surprised to find that many of the grants duplicate programs or departments already in place. While this list is by no means comprehensive, I thought I would provide a few comments on a few of these grants shown in italics):

• Grant program for "community-based collaborative care"
  (Seems this is really a grant to fund telemedicine programs and HL-7 hospital coding standards so computers can talk together. While ultimately this should be a good thing, the grant actually has little to do with collaboration of health care in the community right now.)


• Grant program to develop infant mortality programs
  (Why is more money needed when a department already exists for this?)


• Grant program for reducing the student-to-school nurse ratio in primary and secondary schools
  (Forget teachers, stick with nurses for schools I guess)


• Grant program so "No Child is Left Unimmunized Against Influenza"
  (And yet, I'm sure we'll soon have a Pay for Performance measure for that)


• Grant program to implement medication therapy management services
  (Once again, never mind this has already been done)


• Grant program for community-based overweight and obesity prevention
  (been there, done that, but it seems we can never get enough of this.)


• Sec 2221 (pg 1246) Grant program for nurse-managed health centers
  (APN's doing "primary care." Can't help wonder why the AMA loves this bill. Where's there support of what we do?)


• Grant program to support demonstration programs that design and implement regionalized emergency care systems
  (already being done in certain communities. The natural question is how much money is anticipated for the multitude of communities in need.)


• Grant programs to prepare secondary school students for careers in health professions
  (What ever happened to "Career Day?")


• Grant programs for community prevention and wellness research (What is "wellness" anyway?)


• Grant program to promote positive health behaviors in underserved communities
  (Sounds like attitude adjustment training: "Don't worry, be happy," I guess. Interesting that Senate Bill 319 already addresses this for women and children. Men, it seems, don't matter.)


• Grant program for state access programs (These grants already exist, too!)


• Grant program for national independent monitor pilot program for skilled nursing facilities and nursing facilities
  (What is this? An independent monitor to "oversee" large chains of skilled nursing facilities for some defined period of time. What about Medicare's Nursing Home Compare program?


• Grant program for training in dentistry programs
  Already exists


• Grant programs for innovations in interdisciplinary care (Yep, got this in place already, too)


• Grant program for health insurance cooperatives
  (Helpful cash for insurance interests


• Grant program for wellness programs to small employers
  (I can hear it now: "Don't drink, eat or smoke too much..." and place some nice posters on your wall...)


• Grant program to disseminate best practices on implementing health workforce investment programs
  (A bill already exists on the House floor: H.R. 2810)


• Grant program for national health workforce online training
  (looks like medical schools might be in trouble!)


• Grant program for state alternative medical liability laws
  (a grant to see if liability reform might work - fair enough - but will it change anything?)


• Grant program for public health infrastructure
  (um, don't we already have an Office of Public Health and Science?)

But the "demonstation project" that was created specifically for lawyers: Section 2537 (pg 1464) - a demonstration project of "grants to medical-legal partnerships" was most concerning.

What's this you ask? Is it for health care?

Not really. It's actually a grant just for lawyers who practice poverty law so they can "assist patients and their families to navigate health care-related programs and activities" for the next five years. Never mind that's why we have doctors, nurses and social workers.

Bottom line, there are plenty of places this bill could (and should) be cut to save costs.

But hey, when it comes to health care reform, it seems there's something for everyone when the taxpayer's paying!

-Wes

Quiz of the Day: The Distance Traveler

Q: What's a hundred years old and has traveled over 5 million miles?

A: Would you believe a basketball?

-Wes

Where Treatment Guidelines Fall Flat

... when cases don't follow the rule book:

All of the planned means of tackling Stellan's SVT today during his ablation failed initially. Heart block was induced each and every time from each and every angle they tried to ablate. Dr. A and his team were left with little choice but to ablate Stellan's AV node in order to get rid of his accessory pathway. But before they did, one of Dr. A's colleagues threw out a wild idea.

"Let's try to go through his aorta."

Not in the plan. Not even in the possible or hypothetical plans. Not considered safe or feasible or wise on a 10 kilo baby. But with few options left before destroying Stellan's node, they decided to risk it.

To be honest, I'm glad I didn't know about it at the time.

So from his groin, they threaded the catheter up into his aorta, down into his atrium and through his valve toward his ventricle. From that angle, even though Dr. A said they were in the exact same spot as they'd tried ablating earlier, there was a money shot. He tried cryoablation. It started to zap his SVT with no heart block. So he tried a little more cryo. Again, no heart block.

So Dr. A pulled out the big dog. The radio frequency ablation catheter. His ultimate goal was to get 2 to 3 seconds of ablating done, even if it destroyed his node.

1 second. 2 seconds. 3, 4, 5.

From that angle, through the aorta, Stellan's AV node remained untouched.

Unbelievably, Dr. A was able to crank up the wattage and ablate Stellan's extra pathway for one solid minute before declaring his pathway dead on arrival.

And his AV node is as happy as the day is long.

Certainly this case didn't "Get With the Guidelines" and might not be the approach most would take in this circumstance. Huge risk was involved for the pediatric electrophysiologist: a higher incidence of stroke for the child, unknown long-term affects to the aorta, a potential to injure the coronary arteries, and a large risk to one's professional career if anything went wrong.

At yet, the doctor considered all other options and did what he thought was best for the child given the circumstances...

... then hit a home run.

And judging by the picture of the child in the referenced blog's sidebar, it looks like the doctor did a pretty fine job.

-Wes

h/t: A faithful reader.

Bloggers Can Make a Difference on Veteran's Day

Meet the Eleven Eleven Campaign -- a nationwide campaign by BeyondTribute.org to change the way America honors its Veterans by hoping to raise $11 from 11 million Americans beginning (when else?) but November 11th.

To learn more about the campaign and how you can help make this November 11th a day when bloggers come together to support our Vets, join the conference call Monday, November 9th at 8 pm ET/7 pm/CT/5 pm PT.

Please RSVP to the conference call here:

http://action.eleven-eleven.org/t/5400/signUp.jsp?key=2817

Dial-in Number: 1-213-289-0500

Participant Access Code: 4670471

-Wes

h/t: Glenn Reynolds at Instapundit.

220-215

House Bill 3962 passed by the narrowest of margins.

I find it interesting that when others parse the implications of the bill's passage, doctors aren't mentioned.

Kind of says it all.

-Wes

Criminal Penalties For No Insurance Possible Under Pelosi Bill

From a letter from the the non-partisan Joint Committee of Taxation from Rep David Camp to explain penalties for not carrying insurance under the Pelosi Bill (H.R. 3962):

Americans who do not maintain “acceptable health insurance coverage” and who choose not to pay the bill’s new individual mandate tax (generally 2.5% of income), are subject to numerous civil and criminal penalties, including criminal fines of up to $250,000 and imprisonment of up to five years.

Is this what American's want, criminal penalties including jail time?

If not, I'd suggest you call, fax, or e-mail your Congressman today.

-Wes

Reader Poll: Should House Health Care Bill Pass?

With the US House of Representatives set to vote on the ‘‘Affordable Health Care for America Act’’ (H.R. Bill 3962) this weekend, should the bill pass?

Vote in the sidebar and feel free to leave any comments you'd like to make below.

-Wes

P.S. I'm not tracking URL's nor marketing - promise - just interested what others who read this blog think.

Cardiology Consolidation Continues

This time, in Kansas City:

Cuts of the magnitude envisioned by Medicare, Holkins said, would present “a significant problem for the revenue side of our business model.”

The 14-physician practice, which has roughly 80 employees, has been independent since its founding in 1975.

So, Holkins said, the decision to affiliate was not taken lightly.

“I have really liked the idea of being independent,” he said. “But I also like to be able to pay our employees well and have enough left so our physician partners make a comparable salary to their peers in Kansas City, and I saw that as something I would not be able to do going forward.”

-Wes

Reading the Fine Print of Government-Run Comparative Effectiveness Research

This week, the New England Journal of Medicine published the comparative effectiveness research trial "ROOBY" comparing conventional cardiac bypass surgery to off-pump bypass surgery. The study was conducted at VA medical centers and randomly enrolled 2203 patients between conventional bypass and off-pump bypass surgeries. The study concluded "At 1 year of follow-up, patients in the off-pump group had worse composite outcomes and poorer graft patency than did patients in the on-pump group. No significant differences between the techniques were found in neuropsychological outcomes or use of major resources." Excellent reviews of the trial (with associated surgeon commentary) are provided at theHeart.org and at MedPageToday.com.

What I found interesting was the fact that over half of the operations in the trial were performed by surgical residents. (Admitedly all surgeons had to have a minimum experience of 20 off-pump procedures, but the median off-pump experience by surgeons in the trial was 50 procedures.)

I wonder, where were the senior surgeons at the VA?

-Wes

Cancer's Miracle

It's a strange thing, cancer.

It renders the greatest intellect impotent.

Families coalesce, grapple, then muster their courage to confront the reality, their angst cloaked in platitudes and favors. Certainly there must be something we can do!

Slow. Gradual. Relentless. And yet it's moving too fast.

I wake at night to my wife's restlessness, the thoughts of her mother circulating. Why her? Why now?

A sniffle, a sigh. There is little I can do.

The relentless march goes on, the cadence quickening.

We realize now what's important; her mother's gifts to us a gem.

-Wes

One Special Operation

Real life is so much better than Grey's Anatomy.

-Wes

A Cardiology Fellow Saves a Life on the Subway

Dr. Sonia Tolani, 32, a first-year cardiology fellow at NewYork-Presbyterian/Columbia, notches her belt with another save after 20 minutes of CPR on the subway...

"Stayin alive, stayin' alive, ah ah ah ah..."

Nice work!

-Wes

Do the Ends Justify the Means?

John Cassidy of the New Yorker thinks so:

So what does it all add up to? The U.S. government is making a costly and open-ended commitment to help provide health coverage for the vast majority of its citizens. I support this commitment, and I think the federal government’s spending priorities should be altered to make it happen. But let’s not pretend that it isn’t a big deal, or that it will be self-financing, or that it will work out exactly as planned. It won’t.

Many Democratic insiders know all this, or most of it. What is really unfolding, I suspect, is the scenario that many conservatives feared. The Obama Administration, like the Bush Administration before it (and many other Administrations before that) is creating a new entitlement program, which, once established, will be virtually impossible to rescind. At some point in the future, the fiscal consequences of the reform will have to be dealt with in a more meaningful way, but by then the principle of (near) universal coverage will be well established. Even a twenty-first-century Ronald Reagan will have great difficult overturning it.

Regretably, this analysis is where we're heading: who cares what it costs, just enact it!

God help us when the check comes due.

-Wes

Health Care Insurance Gift Cards

... for Florida residents, they're just in time for the holidays!

Starting this month you can find these gift cards at any Winn Dixie and in November you can find them at CVS pharmacy stores.

There are two types of gift cards available. One is called "the blue health care card" It acts like a temporary health insurance. For $59.00 it gives you health insurance coverage for one to 2 1/2 months based on your age. Here's how it works. You buy the gift card at the store, and the person receiving the card activates it. Then they enroll in a variety of plans offered. After that, you'll receive a package in the mail with a member id card.

You can use the temporary insurance gift card to see a doctor, a dentist, at the pharmacy, or for lab work.

The other gift card is called the family blue discount card. It's $19.00 but unlike temporary insurance, this one gets you 3 months worth of discounts on dental, prescriptions and vision services.

Just be sure you know when you're going to get sick!

-Wes

Are Pharmacies Getting Flu Shots Before Doctors?

From the Chicago Tribune:

"I am a pediatrician in suburban Cook County. We signed up to receive the vaccine, and have yet to get it. I hear it is going to go to local pharmacies before we get it. They only vaccinate children 9 and above. ... Who is going to ensure that infants and asthmatics get vaccinated?"

The response from the Illionois Department of Public Health's spokeswoman Kelly Jakubek was telling:

"We currently are only placing orders for hospitals and health departments, which we consider the front line of health care," she said.

Chicago vaccine providers are under a similar system in which the first shipments go to places that serve the most at risk, said Dr. Julie Morita, medical director of the Chicago Department of Public Health. Her department places the orders and selects the providers to get the first H1N1 vaccine shipments.

"Our priority is to get the early vaccine to high-risk providers," Morita said, "and once the majority have gotten vaccinated, then it can go to retail providers. We can't guarantee a limitless supply, so there may be breaks in supplies for a time, and then get orders filled later on."

It is difficult to know whether Dr. Morita bases her decision on places that have a high incidence of the disease (the frequency of development of a new illness in a population in a certain period of time), or a high prevalence (current number of people suffering from an illness in a given period of time). Pediatricians offices might have a high incidence, but very low prevalence, of flu relative to large chains stores, and if prevalence is what matters to the health department (and politically this would seem so), then pediatricians might be last in line for the shots.

-Wes

A Little Electronic Health Record Satire

SEEDIE (The Society of Exhorbitantly Expensive and Difficult to Implement EHR's) (the same organization that certified Extormity) issues it's definition of "meaningful use:"

"What is meaningful use?" asked executive director Sal Obfuscato at a recent SEEDIE executive retreat in Belize. "We believe the question is the answer, as man has always struggled to find meaning in this world."

This insight led SEEDIE to suggest that certified EHR vendors should embed quotes from well known philosophers in their applications. This approach will prompt physicians and other caregivers to actively seek meaning as they document patient encounters.

"When I am treating a patient, a thought-provoking quote from Jean Paul Sartre or Voltaire is far more valuable than the ability to e-prescribe or adhere to evidence-based guidelines," said Dr. Timothy Farragut, a Vermont pediatrician and SEEDIE board member. "You get so caught up in diagnosing a condition that you forget to ask yourself the important questions - why am I here, what does it all mean, can I still make my tee time?"

These recommendations are part of a SEEDIE effort to be designated as an ARRA certification body. "Unlike certification organizations that focus on subjective functional requirements, our innovative approach to meaningful use is focused on a much deeper meaning of the word meaning," said Obfuscato.

Heh.

-Wes

EP Woo: Electrohypersensitivity Syndrome

Do you have headaches, difficulty concentrating, insomnia, heart irregularities and headaches, fatigue, poor short-term memory, difficulty sleeping, skin problems, tinnitus, nausea, and dizziness? You might have electrohypersensitivity syndrome, a variant of "cell-tower blues!"

Yep, conclusive data gleaned from a study of twenty-five whole patients out of 100 to be studied has discovered at least one example of a "DECT" (aka Digital Enhanced Cordless Telecommunications in the 1.9-2.4GHz band) cell phone causing increased heart rate and irregularities!

Never mind that actual signals are not included in the data, but only a graph of "R-R intervals."

(Um, in case you were wondering, noise will cause variations in surface EKG signals and shortening of RR intervals.)

But don't pay attention to details. It is now clear that electrohypersensitivity syndrome clearly affects a significant proportion of America's teenagers...

-Wes

When Hoop-Jumping Becomes Patient Care

"Doc, I've got good news and bad news."

"What's that?"

"Well, I've lost six more pounds!"

"Wonderful! What's the bad news?"

"Well, you know that new-fangled drug you gave me that works so well for my atrial fibrillation?"

"Yes."

"We'll, I'm part of that AARP Medicare Advantage Part D drug plan, and I just got the "partial" approved drug list for 2010 in the mail. My drug's not on the list, so I called and found the drug's been moved from a Tier II drug to a Tier III drug. That means it will cost me twice what I paid for it this year. That's gonna be tough, doc. I can't afford it.

But I also read that if you call this '800' number and speak to them, they'll allow me to obtain an exemption to keep the drug on Tier II for next year."

I called the number as I typed his note. The patient seemed pleased that I'd be so attentive to his needs during their office visit. A sophisticated voice-recognition triage prompt answered:

"If you're calling about an injectable insulin question, say 'insulin,' drug issue say, 'drug,' if not part of this list, say 'other,'..."

"Drug," I said. a brief pause occurred, then:

"Just a moment..." (Soft music played in the background.)

Finally, a woman answered. he was quite pleasant as I explained the situation. Finally, I got to the part about the patient's drug not being on the 2010 drug list.

"Oh, 2010?" she asked.

"Just a moment."

On hold again. We continued our office visit. "So, how often are you having those episodes of..."

"Dr. Fisher?"

"Yes?"

"What other drugs has the patient failed?"

We listed them: "Atenolol, Sotalol, Amiodarone..."

"And when were those drugs used?"

"Um, seriously?"

"Yes, I need dates."

"Well, according to the fancy-schmancy electronic record, he's been on this Wonder Drug since November 12, 2007... his Amiodarone was stopped then."

"But the other drugs, when were they started and stopped."

I made up some dates. I was not about to spend time culling the record for these dates, but it was clear that data entry fields were being placed on the opposite phone line. I suggested to my patient he write down those dates.

"And why was the Amiodarone stopped?"

I looked at my patient. He quickly reminded me about the lung findings and liver toxicity he had experienced. I spewed the information to the inquisitor in hopes of expediting the interview. It was taking entirely too long. I looked at my patient. This would be his visit. His priorities were set: money talks after all. So I continued. After submitting the answers, she responded:

"Just a moment while I give this information to my supervisor."

Soft music played again. I looked up at my patient. "Um, where were we? Oh, yes, how often have you been..."

"Dr. Fisher?"

"I've given the information to my supervisor."

"Okay, will he receive his Tier exemption?"

"Oh, we've not received the final list yet for 2010."

"But my patient called and discovered this drug was moved from Tier II to Tier III. Why does he know the information and you seem puzzled by the list?"

"As I said, we're still waiting for the final list..."

It was obvious that the discussion was going nowhere.

"So how will Mr. Smith know if he's been granted the exception?"

"My supervisor will review the application for the Tier review and make a decision. Is there anything else you need?"

Realizing that there was no way I was going to get an answer, I acquiesced. "No, I think we've handled the application. Thanks for all you help. By the way, in case my patient would like to check on the application, what's your name?"

"Christine."

"Thanks, Christine. And your last name?"

"It's just Christine."

"Uh, okay. And how about your supervisor's name?"

"Jericho."

"Jericho who?"

"There's only one Jericho here," she said.

I could only think one thing at that point as I hung up:

... I bet he's a "wall."

-Wes

Not Seeing the Forest for the Trees

Congress, in their efforts to be conciliatory to specialists, is now working to alienate primary care physicians, too:

(Medicare payment) Reductions will be made over four years rather than imposed at once in 2010, the U.S. Centers for Medicare and Medicaid Services said yesterday in a statement. In July, the agency said it planned to slice $1.4 billion, or more than 10 percent, in payments for each of the two specialties, triggering what an advocate promised would be a “tooth and nail” battle.

The administration argued that the lower reimbursements for specialists would make more dollars available for lower-paid non-specialists who can focus on preventing expensive, chronic illnesses. That would tame the growth in medical costs, one goal of President Barack Obama’s effort to remake the U.S. system of care. Under yesterday’s plan, family doctors and nurse practitioners would get half the proposed increase.

So while specialists won't be cut quite as bad, primary care will not see their efforts rewarded significantly either.

And yet, any real effort to look for simple ways to cut costs in health care system is ignored by Congress. One only has to look at the waste of health care dollars implicit in pharmaceutical direct-to-consumer advertising - and the fact that only two countries in the world (the U.S. and New Zealand) permit it - to see the hipocracy of the reform efforts underway. Instead, doctors are the easy target for "reform" as more and more ads for Viagra, Lipitor, and "P.A.D." flash accross our TV screens.

Sure it's not the only place costs can be cut. But how about ridding our system of such bloat before biting the hand that cares for us?

-Wes