Health Care's Road to the Supreme Court: Two Judges For, Two Against

With Florida judge Vinson's ruling today ruling the that portions of Obamacare may be unconstitutional, the rulings of various state's district judges is tied 2 to 2:

As noted at the outset of this order, there is a widely recognized need to improve our healthcare system. How to accomplish that is quite controversial. For many people, including many members of Congress, it is one of the most pressing national problems of the day and justifies extraordinary measures to deal with it. However, “a judiciary that licensed extraconstitutional government with each issue of comparable gravity would, in the long run, be far worse.” See id. at 187-88. In this order, I have not attempted to determine whether the line between constitutional and extraconstitutional government has been crossed. That will be decided on the basis of the parties’ expected motions for summary judgment, when I will have the benefit of additional argument and all evidence in the record that may bear on the outstanding issues. I am only saying that (with respect to two of the particular causes of action discussed above) the plaintiffs have at least stated a plausible claim that the line has been crossed.

Accordingly, the defendants’ motion to dismiss (doc. 55) is GRANTED with respect to Counts Two, Five, and Six, and those counts are hereby DISMISSED. The motion is DENIED with respect to Counts One and Four. Count Three is also DISMISSED, as moot. The case will continue as to Counts One and Four pursuant to the scheduling order previously entered.

DONE and ORDERED this 14th day of October, 2010.
/s/ Roger Vinson
ROGER VINSON
Senior United States District Judge

To summarize so far:

FOR:
George Caram Steeh of Michigan

District Judge Norman K. Moon of Virginia

AGAINST:

District Judge Henry Hudson from Virginia's ruling on Minimum Essential Coverage Provision of the law

Rodger Vison's ruling from Florida today.

-Wes

What's Next, Carding Doctors?

It was en international doctors' meeting and had been a long morning of running between sessions. The brief break before the late-morning sessions was underway and doctors were streaming into the exhibit hall. The Merck booth was spacious and had a pleasant gentleman wearing a conventional hall uniform with white gloves behind a counter with two ornate large coffee pots and small cups behind the counter. The line of conference-goers stretched some distance, as the bleary-eyed and shoulder-bag-laden attendees waited for their cup of "joe."

And there it was, a sign, prominently displayed at the corner of the counter:

While I never saw the poor guy behind the counter card a doctor who approached his counter, I wondered how this law for physicians from the great states of California, Massachusetts, Minnesota, or Vermont was to be enforced exactly.

Oh yeah, the honor system.

Who knew?

-Wes

The Eroding Physician Brand

It came as a Twitter 'follow' this morning from '@coldfeet65,' a self-proclaimed 'Nurse Practitioner Hospitalist.'

I had never heard this term before.

Does it mean a Nurse Practitioner who cares for Hospitalists? Or is it a Hospitalist who is a Nurse Practitioner? Or maybe it's a Nurse Practitioner who helps Hospitalists? (Honestly, I think I know which one she means, but you get my point.)

Perhaps this is a prescient glimpse to health care of the future, where our more typical nurse and doctor labels are supplanted by more and more monikers that serve to confuse, rather than clarify, each of our roles in health care delivery. As specialists in cardiology, we've seen a similar trend with cardiology hospitalists.

But we should be clear what this means to the patients and doctors going forward.

No doubt most people in America still expect to see a doctor when they come to the hospital. Increasingly, it appears that might not be the case. Your doctor might be a robot while a nurse (aka, nurse practitioner) will be the one providing the hands-on care in the inpatient setting. Is that a good thing?

Honestly, I'm not sure.

No one argues that the costs in health care need to be cut. No doubt the Central Authority has deemed that doctor salaries will be a big part of that effort. Already, 20 states have cut physician Medicaid payments for fiscal year 2010 and, given the current economic pressure on our states both now and after they start feeling the financial impact of the "Affordable" Care Act in 2019, this trend is not likely to improve anytime soon. As a result, we are seeing that the world is full of "creative solutions" to our health care access crisis and the evolution to Nurse Practitioner Hospitalists might be one of these.

But what are Doctors of Medicine becoming as a result? Are our current cohort of primary care doctors becoming little more than nurse managers and fact-checkers of mandated protocols, treatment guidelines, and care directives?

Hopefully not.

But increasingly it appears that those without a hands-on, invasive skills in medicine (like surgery) are being marginalized in the health care models going forward. This trend now appears to even be affecting the much-heralded inpatient hospitalist care model as the doctor shortage intensifies. Consequently, the image of "doctor" as we knew it is changing, not only for what patients can expect to encounter when they come to a hospital, but for the type (and caliber) of the doctor we attract to our profession going forward.

-Wes

Social Media and the Challenge of Overcoming Intellectual Complacency

They lined the walls in a warm room as far from the central table as possible. They had come to learn about EKG's. Residents of at varying years of training sat amongst the interns, much the same way as the Democrats sat amongst the Republican's at the recent presidential State-of-the-Union address: cordial - not too aloof.

I was fortunate to be the lucky guy to teach them that day. I have always enjoyed this opportunity and generally the lectures seem to be well-received and attended. This was lecture toward the latter part of the year, so things were not the chip-shot tracings that most learn in ACLS. Still, we always harken back to the fundamentals of reading tracings to help us understand new concepts, but I encountered a strange silence when I discussed the EKG's of patients with pacemakers:

"We all hear the phrase "He's got a DDD pacemaker," right?

They all uniformly nodded they'd heard the phrase, so I asked further:

"What do the letters in the term 'DDD pacemaker' mean?"

Silence overcame the room.

Perhaps I had caught them off guard. Many of their eyes fell to the floor. Some smiled but failed to answer. Some were clearly unnerved by the question as they shifted in their seats. A cough could be heard in the corner - it might as well have been a pin dropping. In the back right-hand corner a pager sounded. Everyone turned to the lucky contestant who was saved by the beep. Finally, somewhere toward the opposite corner of the room came a faint suggestion:

"Isn't one of them mean which chamber is paced?"

Relieved, you could see a few heads nodding now.

"Which letter of the three represents that?"

Again, the room fell silent.

Needless to say, we moved on from there after a quick basic review of pacing terminology, but his got me thinking: where have we failed to teach our medical students and residents such fairly basic clinical concepts and vernacular we use every day? Are we spending too much time on the Krebs cycle and not enough time on clinically relevant concepts in medical school and internship? How do we get them to remember?

So I had an idea: what if I used social media?

We all know that every medical student and resident (and doctor and patient, for that matter) has a cell phone. Might we use Twitter to try to teach small snippets of information to our trainees? Obviously they would have to have a Twitter account. Also, not all concepts lend themselves to this appraoch very well, but it might be worth a trial.

Soooooo, look for an occassional Electrophysiology Quiz via Twitter from yours truly. (Others with ideas for ultra-short cardiac electrophysiology quizes are welcome to join in the fun, just use the hashtag '#epquiz' in your tweet.)

Soon, there might be an entire library of fun questions and answers for all to enjoy on Twitter that are easy to catalog! And who knows? Maybe some of our more engaged students, interns, and residents on social media just might remember a thing or two while contributing to the fun.

-Wes

You Know It's Bad When,,,

... the attending surgeon has to write this at the beginning of his operative note:

"I certify that the services for which payment is claimed were medically necessary and that no qualified resident was available to perform the services."

So there you have it.

-Wes

Game Day

Division rivals. Historic. Unequaled. Epic.

Hope it's close.

Go Bears!

-Wes

P.S.: BTW, are those defibrillator patches?

For The Doctor's Dinner Table

A heart-shaped porcelain salt shaker.

-Wes

From LikeCool.com via Holy Kaw.

DOJ Investigating Defibrillator Implanters

From the Heart Rhythm Society member's website today:

"The Heart Rhythm Society (HRS) is aware of an ongoing U.S. Department of Justice (DOJ) civil investigation of Implantable Cardioverter Defibrillator (ICD) implants and has agreed to assist in an advisory role to lend expertise concerning proper guidelines for clinical decision making. As an advisor to this investigation, HRS is reviewing information that does not include either identifiable patient or facility level data. Rather, we are providing insight on the field of electrophysiology to the DOJ. Because this is an ongoing investigation, HRS Staff or Leadership is not available for further comment. HRS will communicate additional information to its membership when permitted to do so by the DOJ."

This action comes, no doubt, on the heels of the recent publication in JAMA which reviewed an ICD registry of implantation practices in America from 2006 to 2009 and found 22% of ICD implants were implanted outside published guidelines.

Now all of us know people make money implanting ICD's, including me. Given the time, the expertise, and the management issues involved with the 24/7 care of the patients with these devices, they should.

But no one wants to waste money to our health care system, either, and we must acknowledge there's been a heck of a marketing push to get more devices implanted. This has occurred because many patients who might benefit (legitimately) from these devices remain untreated and, yes, hospitals and medical device companies benefit handsomely from these procedures.

But before witch hunts ensue, we should take a moment and consider the implications of the DOJ's current actions.

First of all, I think most of us would acknowledge that every set of clinical guidelines published has holes. (One only has to look at the latest published atrial fibrillation management guidelines to note that the use of the newly-released anticoagulant dabigatran (Pradaxa) is not mentioned in those guidelines, rendering them already obsolete). Further, the studies upon which recommendations are made in published guidelines are often made on relatively weak data or by people with substantial industry ties. Further, prospective randomized trials are rarely used to make those recommendations.

Simply put, there is no way a published document can cover every clinical circumstance a doctor might encounter when he or she is in the trenches with an individual patient.

So this begs a simple question: If guidelines are not perfect and we must accept that doctors must deviate from them from time to time to work toward the best interest of their patient, what IS the percentage of care (in this case, ICDs) that SHOULD fall outside of guidelines?

Is 0% the correct number?

Clearly, no.

Is 5%, 10%, 15%, 20%, 22%?

The reality of this situation is that no one knows.

But that does not seem to be stopping the DOJ from investigating doctors for their criminal intent...

... based on the guidelines, of course.

-Wes

References:
Al-Khatib SM, Hellkamp A, Curtis J, et al. Non-evidence-based ICD implantations in the United States. JAMA 2011; 305:43-49.

Dr. Rich over at the Covert Rationing blog appropriately rips the abuse of the ICD guidelines in his must-read essay.

John Mandrola, MD, another EP, gives his take.

Larry Husten, at Cardiobrief, summarizes.

21 Jan 2011: An now, thanks to new SCD-HeFT data, maybe the 40-day wait period post-MI for ICD's is not such a good idea. Oh wait, that's not in the guidelines.

The Results Are In: Age vs. Typing Speed in Medicine

Thanks to all who offered to take my highly scientific study (not!) of internet-saavy medical professionals that utilize the blog-o-sphere. I added all twenty-nine of your responses to an Excel spreadsheet and produced a scatter plot (complete with linear regression line and correlation coefficient) for your amusement:

Note that the effect of a prior typing class nor staff rank were not included in the analysis. (I'm saving the same study comparing subspecialies for my next peer-reviewed journal article.)

It seems the younger generation will be well-equipped to work with the electronic medical record, courtesy of text-messaging and gaming.

:)

-Wes

How Fast Are You?

"My goodness, Mildred, look how fast he types!"

I hear this all the time during my clinic visits. (What they don't realize is that many of those keystrokes are the backspace key to edit mistakes I make while typing.)

But I thought it would be interesting to take a poll for a pseudo-scientific study (i.e., just for fun) using my friends and family from the blog-o-sphere and our lab to determine one of the most important dependent variables influencing the use of electronic medical records (EMRs): typing speed!

The results from some of the staff in our hospital are listed below:

Age	Staff Position	Words/min	Errors	Typing Class?
34	EP Fellow	71	6	Yes
52	EP Attending	40	2	No
50	CV Attending	30	2	Yes
58	CV Attending	24	0	No
38	EP Attending	52	6	Yes

It would be fun to see what your typing speed is, too!

So here's how to add your data to the mix:

1) Go to typingtest.com.
2) Take the 1 minute typing test and record your typing speed calculated by the program and include the number of errors it found as well.
3) Enter your (a) age, (b) staff position, (c) Net typing speed in words per minute (the one AFTER the errors are subtracted out), (d) the number of errors you made, and whether you have ever had typing class or not, then enter the results in the comments section. If you make a mistake, take the best result from the first three tries from the test.

This might just become the single largest depository of documented medical errors on the internet!

Of course, it also explains why there is a propensity to keep EMR documentation on patients very, very brief.

-Wes

Medgadget Hosts the 2010 MedBlog Awards

... for the seventh straight year:

The categories for this year's awards are:

• Best Medical Weblog
• Best New Medical Weblog (established in 2010)
• Best Literary Medical Weblog
• Best Clinical Sciences Weblog
• Best Health Policies/Ethics Weblog
• Best Medical Technologies/Informatics Weblog
• Best Patient's Blog

Nominations are now accepted in the comments section of their post. When nominating, please indicate the blog's name and URL, nominating category, as well as your thoughts why this particular blog deserves recognition. A blog can participate in more than one category, so please be precise which one(s). When we have all the nominees, Medgadget editors and Dr. Allen Roberts from GruntDoc will sort through all the blogs, and we will select up to five blogs in each category based on merit, and on our own internal voting results.

The following time line will be observed:

Nominations will be accepted until 23:59:59 Sunday, January 23, 2011.

We will announce the finalists on Monday, January 24, 2011.

Polls will be open from Thursday, January 27, 2011 and will close at 23:59:59 EST on Sunday, February 13, 2011.

Winners will be announced on Friday, February 18, 2011.

Medgadget, as well as the individual blogs of our editors, are not eligible to participate in the awards.

It's very cool these guys do this each year.

-Wes

First Diagnosis

They lived in a high-rise apartment complex - five stories - maybe 40 apartments in all. It was neatly kept, had a functional elevator, but was hardly a place you'd want to bring your mother to view. Probably the best word for it: functional. But he didn't care - he was a first year medical student. One bedroom, bath, kitchenette, 5th floor. "Penthouse suite," he'd call it.

He rarely interacted with his neighbors, except to exchange a courteous "Good morning" with them as he closed his door to attend the morning's lecture or perhaps an occasional "'night" as he unlocked his door upon returning home. But she lived three doors down - a charmer, frail, maybe eighty, wearing galoshes, and a hint of a flowered skirt beneath her undersized long winter coat. "Nice to have a 'doctor' on the floor," she beamed as she fumbled for her keys.

"Not quite yet," he'd say in return, but she never heard him. Hearing aides, schmearing aides. Damned if she'd ever wear them.

And so it went: a rare exchange of pleasantries, but not much more. Human anatomy, cytology, and human physiology were really what mattered to him at the moment. School was all consuming and he was doing well this first semester. The formula he had imagined to become a doctor was founded on an unswerving work ethic that he'd learned though college and studying for the MCAT's: read, memorize, regurgitate. Read, memorize, regurgitate.

Nothing to it.

Lather, rinse, repeat.

To her, she was focused on her son. He was moving in with her. "He needs a place to stay," she'd tell him. "Lost his job." And so, the groceries in her pull cart were unusually heavy this day as the student arrived home. She asked for help, and he obliged.

Her apartment was like his, but filled with pictures - some adorning the wall, some of the hall table, most on the refrigerator. A black and white with a young couple at the wedding. "Was that your husband?" "Yes," she replied, "... died of cancer of the stomach." He wished he knew more about cancer of the stomach, but said "I'm sorry" instead. And there, on the refrigerator was the picture of a massive man hugging to her frail body. "That's Tommy, my son," as she pointed to the picture. "He's all I've got now. It'll be good to have him home from the hospital."

"Hospital?"

"Well, not really a hospital, rehab. He's got's lots of problems, but his biggest one is drinking. He's had a tough go. Diabetes. Sleep apnea. You know." He really didn't know, but they made short work of emptying the grocery bags. "Thanks so much for your help."

He returned to his apartment down the hall and was glad he still had time to study for there seemed to be no end to the things he didn't know about. "How am I going to learn about all of this?" he wondered.

Weeks passed and the student caught glimpses of the large man. Simply put, he was huge, particularly when you compared him to her. But he was seen helping her with the even larger load of groceries and soft drinks on more than one occasion. The hallway was always the place for pleasantries, after all. Only later, behind closed doors, did he occasionally hear the shouting: "You've got to get help!" she'd plea. "I'm not giving you more money, dammit." Another expletive, a slammed door, then the elevator arriving to usher someone downstairs. A few hours later: pounding on the door, "I'm sorry, Ma. You gotta let me in." The door would creak open, then close.

And so it went. Her game face would be on each time she saw her 'doctor' in the hall. A gentle smile, a tacit signal that she was okay. He was too shy, too ignorant, too embarrassed to inquire about how it was going. He knew. "Good night," he'd say.

Until the day the medical student made his first diagnosis.

The early morning pounding at the door, the panicked face, the tears, the "Please come, quick!", the terror, "I've called 911," were not there in his textbooks.

Nor was the pallid face, the glassy half-opened eyes staring up, the crimson under-surface of his shirtless chest.

"My God! He'd been out most of the night, " she explained. "Just laid on the floor in the back hall and said he was exhausted. Wanted some breakfast. Didn't think about it... I kept cooking. The stove fan. I never heard him. We were out of eggs, so I went to get some. I came back and I called to him, he didn't answer."

She stopped and turned to the young doctor-to-be, searching his face, tears flowing, "Is he.... is he... ", her voice cracked, "... dead?"

He didn't have the heart to tell her he'd never seen someone dead before. How do you do this? Breathing? None. He sure looks dead. He went to his side and checked for a pulse. That cool, unmistakable almost gray-white skin had none and highlighted the coal-black widely dilated pupils that didn't move. He remembered the term "livor mortis" and returned to her quivering frame. An ambulance could be heard in the distance coming closer. Time stopped for a minute and he cupped her head gently against his shoulder as he whispered in her ear.

"Yes."

She knew, but she needed to hear it from someone else. She looked up from his shoulder at her son as she regained her composure and used her bent fingers to wipe away the tears from her cheek.

"Maybe now Tommy can rest in peace. Thank you, doctor."

-Wes

Dronedarone and Liver Failure?

Bad news for Sanolfi Adventis from Larry Husten over at Cardiobrief:

Sanofi-Aventis is about to send a “Dear Doctor” letter to physicians informing them of two cases of fulminant hepatic failure/necrosis resulting in liver transplanation in two patients taking Multaq (dronedarone), CardioBrief has learned. The two patients were women in their 70′s with no other apparent causes of liver injury or known elevations of liver function tests (LFTs) prior to the acute liver failure. Liver failure developed after the women were taking dronedarone for four to six months.

CardioBrief has also learned that Sanofi-Aventis plans to change the drug’s label and will recommend that physicians obtain LFTs at baseline prior to prescribing the drug. The company had previously informed clinical investigators working with the drug about the liver failure cases.

Recall the rocky road that Multaq had to travel to gain FDA approval - it was only approved after patients with congestive heart failure were excluded from the drug's pivotal Athena Trial. Post-approval, it was marketed as a safer alternative to Amiodarone so if true, these cases raise new questions regarding this niche for the treatment of atrial fibrillation.

The specifics of the two affected patients remain unknown to me (did they have a history of CHF?) Still, if true, this drug will certainly no longer be one of the initial recommended therapies for paroxysmal atrial fibrillation management as the new 2011 AF treatment guidelines have suggested, and probably won't be used much at all until the dust settles on this story.

-Wes

Addendum 14 Jan 2011: The released FDA Drug Safety Communication on dronedarone (Multaq) contains this clincial information on the two patients with liver failure:

The two cases of acute hepatic failure requiring transplantation occurred at 4.5 and 6 months after initiation of dronedarone in patients with previously normal hepatic serum enzymes. Both patients were female and approximately 70 years of age. In the first case, the patient had underlying intermittent atrial fibrillation, arterial hypertension and stable coronary artery disease. She was treated with dronedarone for 4.5 months. Two weeks prior to hospitalization she reported increased exhaustion and tiredness. One week prior to admission she discontinued dronedarone, and at the time of admission she was noted to have jaundice, coagulopathy, transaminitis and hyperbilirubinemia, which progressed to hepatic encephalopathy over the next nine days. A pre-transplant workup did not reveal another etiology of liver failure. In the second case, the patient had a medical history of paroxysmal atrial fibrillation and Sjogren's syndrome. Following 6 months of treatment with dronedarone she developed weakness, abdominal pain, coagulopathy, transaminitis and hyperbilirubinemia. She was transplanted 1 month later; no alternative etiology for liver failure was identified in the transplant work-up. In both cases, the explanted liver showed evidence of extensive hepatocellular necrosis.

Addendum 1/16/2011: The distributed Sanolfi Adventis "Dear Doctor" letter.

A Fully-Functional Electronic Medical Record Comes to Apple's iPhone, iPad and iTouch

Today, Epic Systems Corporation launched their free MyChart application (app) for the iPhone, iPad and iTouch which at our medical center. The app provides the following functionalities:

• Test Results: View test result values and standard ranges for each result.
• Messaging: View and reply to messages in the Inbox, and create new medical advice request messages.
• Appointments: View and confirm or cancel upcoming appointments, and view some After Visit Summary information for past appointments.
• Health Advisories: View preventive care procedures and their due dates.
• Health Summary: View medications, allergies, immunizations, and current health issues.
• Proxy Access: View all features listed above for family members.

This functionality permits patients access to portions of the actual electronic medical record used by their doctors in a mobile format. A license agreement must be entered into by the patient that permits the use of their iPhone's UDID (unique serial number ID) to be collected, transmitted, and stored on their medical center's designated server for troubleshooting and "audits." As such, user data will be shared with others within the scope of the licensure agreement, including third parties. (Interestingly, "Apple will have the right to enforce the terms of the Licnse against you as a third party beneficiary thereof.") Still, I suspect most will consider this a very small price to pay for timely access to one's health information.

The following providers offer this functionality so far: Baylor Clinic (TX), Buffalo Medical Group, PC, (NY), Dean Clinic (IL/WI), Dreyer Medical Clinic (IL), GHCMyChart (WI), Hawaii Pacific Health (HI), Loyola Medicine (IL,WI, IN), Mercy Health System (IL, WI), Aspirus (MI, WI), The Institute of Family Health (NY), NorthShore University HealthSystem (IL), Oregon Health and Science University (OR, WA), SSM Medical Groups (MI, IL), Sutter Health (CA), Weill Cornell (NY), Wildwood Family Clinic, (IL, WI).

Yep. The wave of the future.

The Cardiologists' Hole Punch

... heart-shaped, of course.

-Wes

Grand Rounds Is Up

Over at the FDAzilla blog:

As you read through the best posts from the medical blogosphere for the week, just think about how amazing all of this is - health care leads to all kinds of misconceptions, frustrations, discoveries, inspiration, opportunities, tragedy, and humor.

This week's pick: how a man in Sweden was forced to have his penis amputated after waiting more than a year to learn he had cancer.

I'm not kidding, the story's there. Check it out, if you dare.

I think the story's cross-filed under "tragedy" and "frustrations."

-Wes

An Internet ID for All Americans?

From CBS News:

President Obama is planning to hand the U.S. Commerce Department authority over a forthcoming cybersecurity effort to create an Internet ID for Americans, a White House official said here today.

It's "the absolute perfect spot in the U.S. government" to centralize efforts toward creating an "identity ecosystem" for the Internet, White House Cybersecurity Coordinator Howard Schmidt said.

That news, first reported by CNET, effectively pushes the department to the forefront of the issue, beating out other potential candidates including the National Security Agency and the Department of Homeland Security. The move also is likely to please privacy and civil liberties groups that have raised concerns in the past over the dual roles of police and intelligence agencies.

The announcement came at an event today at the Stanford Institute for Economic Policy Research, where U.S. Commerce Secretary Gary Locke and Schmidt spoke.

The Obama administration is currently drafting what it's calling the National Strategy for Trusted Identities in Cyberspace, which Locke said will be released by the president in the next few months. (An early version was publicly released last summer.)

"We are not talking about a national ID card," Locke said at the Stanford event. "We are not talking about a government-controlled system. What we are talking about is enhancing online security and privacy and reducing and perhaps even eliminating the need to memorize a dozen passwords, through creation and use of more trusted digital identities."

No, they're not talking about a national ID card, just an international internet ID.

Imagine. Anyone registered with such a cyber-ID who conferences with their doctor via a "secure server" can also be tracked by the government with such a mechanism.

And the issue of not needing more than one password? While convenient, the ramifications of multiple accounts being compromised if a data leak were to occur remains with such a mechanism.

But fear not:

Details about the "trusted identity" project are unusually scarce. Last year's announcement referenced a possible forthcoming smart card or digital certificate that would prove that online users are who they say they are. These digital IDs would be offered to consumers by online vendors for financial transactions.

Schmidt stressed today that anonymity and pseudonymity will remain possible on the Internet. "I don't have to get a credential if I don't want to," he said. There's no chance that "a centralized database will emerge," and "we need the private sector to lead the implementation of this," he said.

No doubt you won't have to be "credentialed" unless you want to use a government service. (They have to be sure you're a "trusted user," right?)

Like Medicare or Medicaid.

Privacy? Who needs privacy?

-Wes

Reference: Draft Document: "National Strategy for Trusted Identities in Cyberspace," (pdf) dated 25 June 2010.

New iPhone Skin Doubles as Single-Lead EKG

Developed by Oklahoma physician and entrepreneur Dr. David Albert, a true single-lead ECG for the iPhone 4 has been created using a unique skin for the device (shown). The iPhone can store a pdf of the signal and also transmit a realtime wireless signal about a foot using the iPhone's battery.

Until now, most other free applications have used the camera feature of the device to display a person's heart rate, rather than their actual electrocardiogram. Here's Dr. Albert's demo video:



Nice.

-Wes

Could a Bra Interact With a Pacemaker or Defibrillator?

The comment was posted on this blog earlier:

"I was reading one of your old posts about magnets and I was wondering if a magnetic front closure on a bra would be a problem? There's a warning on the label but I know part of that is just due to liability. What about the new Victoria Secret bra that has a magnet clasp on the front? If the magnet hits right in between the breasts would it be close enough to the device that it could interfere? Also does having a magnet that close change the settings or turn off a defibrillator/pacemaker early? I'm sure most doctors would say just wear another bra but this bra in particular is very comfy! I've tried it on but not worn it for extended periods of time. Luckily this is one of the only major complaints I've had about having heart disease and a medtronic device at such a young age."

First, let me say thank you for asking this question: who knew research could be so, er, entertaining! Second, this question reinforces why medical blogging is so great: you learn something new every day.

Now, as I slap myself back to a bit more professional stance, I'll summarize by saying I think you'll be okay to use such a bra with some precautions. Given the picture and the clasp's location, this bra is more likely to interfere with the pacemaker of the partner you hug rather than yourself, provided your pacemaker was implanted over 3 centimeters from the magnetic clasp. Since most pacemakers and defibrillators are implanted just below the collar bone, the chance of the magenetic clasp to interfere with your device is remote. From my earlier post:

Pacemakers and defibrillators contain a small "reed switch" that is sensitive to magnetic fields that allows patients and their doctors an opportunity to affect their device to perform specific functions outlined below.

In the case of pacemakers, the activated reed switch tells the pacemaker to pace, irrespective of the person's underlying rhythm, at a specific rate (determined by the manufacturer of the pacemaker). When the rate changes, this tells doctors how much voltage is left in the person's pacemaker, and uses the paced rate to act like a battery meter, telling doctors when the pacemaker battery voltage is getting low. It does NOT inhibit pacemaker output. (Oh, there will be some wise guy that says that pacing that does not synchronize with one's heart rhythm could land in the "vulnerable period" of the cardiac cycle and induce an abnormal rhythm (and yes, that can occur), but magnet checks are done tens of thousands of times a day in the US and I have never heard of someone dying from this with conventional pacemakers).

In the case of a defibrillator (that treats abnormally fast and slow heart rhythms), the reed switch acts slightly differently. Again, a magnet over the person's defibrillator does NOT inhibit pacing at all. In the case of a defibrillator, a magnet over the device that is powerful enough to trip its reed switch will suspend detection of rapid heart rhythms while the magnet is over the device. In the case of this article, this will only happen if a magnet is held within three centimeters of the device. That's only 1.5 inches, folks. In other words, one of these fridge magnets or pieces of jewelry would have to be held virtually right over the device to have any effect. Certainly, if the person had the unfortunate luck that a rapid heart rhythm occurs when a magnet of sufficient strength is over the device, then the device would not detect this rapid heart rhythm and it could be fatal. But the odds of that happening are very, very low.

-Wes

Reference:
Wolber T, Ryf S, Binggeli C, Holzmeister J, Brunckhorst C, Luechinger R, Duru F. Potential interference of small neodymium magnets with cardiac pacemakers and implantable cardioverter-defibrillators. Heart Rhythm. 2007 Jan;4(1):1-4. Epub 2006 Sep 16.

Happy New Year!

Sorry to have been gone so long, but I simply had to recharge my batteries for a while. Thanks to my colleagues and staff at work, I took some time in Northern Michigan with family and friends. Although I loathe loading all of the junk on top of the car for such a trip (too many people traveling to fit it all inside the car), the time unplugged does wonders for one's psyche.

Since my brain's still on neutral, here's a few health-related tidbits I've stumbled across this morning for your enjoyment/consideration:

• When having a heart attack, what's a helicopter ride to the nearest hospital cost when the local bridge is closed? How does almost $10,000 grab ya?
• How to do a photo shoot of your cardiology practice.
• States with business "personalty taxes" (defined as movable, touchable property used in a business, including furniture, computers, machinery, tools, supplies, raw materials, vehicles, scrap, billboards, tanks, pipelines and other property not listed as real estate) want to collect back taxes on reusable surgical kits sent back and forth between hospitals, too. (What will states do if we cut health care costs?)
• A good explanation of why patients are confused by media-directed health care advice.

Happy New Year!

-Wes