The Next Pacemaker Re-Charger

Could it be a solar-powered bra manufactured by Triumph?

-Wes

Ref: More on Video.

Medtronic's Sprint Fidelis Performance Lead Update

It's now been six months since Medtronic's lead recall of their 7-French Model 6949 Sprint Fidelis defibrillator lead in October 2007. The first update of the lead performance arrived in my office this week, dated 7 May 2008 (you can view it here). With this letter came the first trending data of the failure rates as determined by evaluation of Medtronic's Carelink follow-up database and Returned Product Analysis (RPA) reports as well.

While the number of lead failures remains relatively small and current follow-up recommendations have not changed, the failure trends, albeit early, remain concerning. It appears that a continued number of failures throughout the life of the lead can be expected. By Medtronic's analysis of a typical 1000-patient ICD clinic, over the next 12 months, nine (9) patients can be expected to have an anode or cathode failure and half of those patient's will have little warning of an impending fracture.

The implications of these recommendations are far-reaching, for it now seems the fault with the lead was not a physician implant technique problem as originally surmised, but rather a design flaw. Further, when it comes to replacing these patient's defibrillator batteries over the next four or five years, electrophysiologists will likely be advised to replace the 6949 lead with a more reliable defibrillator lead model, like the 6947, increasing the difficulty of a typical device battery change procedure.

-Wes

Physician Gain-Sharing: What a Tangled Web We Weave

In an effort to control costs, it seems the Department of Health and Human Services is exploring physician gain-sharing programs:

The Health and Human Services Office of Inspector General has approved a handful of gainsharing arrangements in which physicians receive cash payments for reducing hospital spending. Gainsharing might reduce costs by aligning hospital and physician incentives, but concerns remain about quality and access.

But there are significant concerns with this approach:

Although the approved programs incorporated safeguards, questions remain regarding whether such narrowly structured programs can effectively reduce costs without harming access and quality. Specific concerns focus on whether physicians respond to gainsharing by limiting their use of quality-improving but costly devices ("stinting") or by treating only healthier patients ("cherry-picking") and avoiding sicker patients ("steering") at their gainsharing hospitals. Because of concerns about cherry-picking and steering, the OIG prohibits payouts to physicians with changes in their patient mix, measured by the prevalence of high-cost, high-risk patients. The OIG also has expressed concern that physicians would increase their caseloads within gainsharing programs, essentially receiving payments for referrals. To limit this, the OIG has required that any savings generated by an increased volume of patients insured by Medicare or Medicaid could not be included in physicians’ payouts. Others have expressed concern that gainsharing might limit patients’ access to new, beneficial drugs and devices.

Note that the "savings" are passed on to the hospital and doctor, but not the patient (nor their insurer).

Are we potentially robbing the poor to pay the rich with this approach?

-Wes

Radiologists Have All the Fun

I found this from this week's Grand Rounds over at Health Business Blog. Very funny.

Damn radiologists have all the best party gags...

-Wes

HRS: Be Sure to Bring Your Lomotil

I'll be heading to the Heart Rhythm Society Meeting in San Francisco tomorrow, and just received this e-mail:

Dear Heart Rhythm 2008 Attendees and Exhibitors,

The Heart Rhythm Society has learned from the San Francisco Department of Public Health that there have been reported cases of what is suspected to be norovirus in the San Francisco area. A number of those affected were attending an earlier event at the Moscone Convention Center.

As you know, Heart Rhythm 2008 is scheduled to take place at the Moscone Center, May 14-17. The Convention Center and city health officials have put measures in place to disinfect the facility and are continuing with the current schedule of events. Therefore, Heart Rhythm 2008 is scheduled to continue as planned.

We will continue to update all attendees and exhibitors via e-mail and ww.HRSonline.org should new information become available.

For more information on norovirus, please visit the CDC website at http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus.htm.

We look forward to seeing you in San Francisco.

The Heart Rhythm Society

Gee, I can't wait...

-Wes

Underpenetration of Implantable Defibrillators

One wonders if this whole mess could have been avoided if this man had had an implantable defibrillator installed before this occurred. I mean, there's such a false sense of security thinking that it's been 10 years since your heart attack, so you must not need a defibrillator.

Well, think again.

-Wes

Skinny or Fat: A-fib Ablation is Effective

Worried fat patients might not benefit as much as skinny patients after catheter ablation of atrial fibrillation?

It seems it doesn't matter.

-Wes

Consumer-Driven Healthcare

I love the term "Consumer-Driven Healthcare." It's so, well, corporate.

God forbid we call it "Patient-Driven Healthcare." At least that might make some sense.

But "Consumer-Driven Healthcare" seems to be what all the buzz is about. Learn which hospital is the highest "rated." Learn which hospitals do which procedures. Learn which hospitals give aspirin to 100% of their acute heart attack victims, or wash their hands, or have saunas and spas, or reiki, or DaVinci robots. With that Great Website out there, "consumers" are gonna have it all! Can't you hear it? "Our website will have a HUGE impact on where you'll get your care. Our website will have all of the information right at your fingertips as your clutching your chest and can't breathe! Our website will even tell you where the most non-foreign trained medical doctors are on staff and how many are board certified, and where those doctors trained - for we tap into a repository of 8,000 databases and cull the data that looks best to us! We'll even let you see how many gold stars they've paid qualified for!"

And the Average Joe (or Janet) Everyman LOVES this empowerment. I mean, what's not to like? Isn't it great? "I'm gonna know everything before I get to the hospital - and what I don't know, hell, I'm just going to look it up on the Great Website!"

What a crock of excrement.

What Joe and Janet don't realize is this: they're patients, not consumers.

If they were real consumers, they'd know what it costs to have a gallbladder removed, or what their surgeon will charge and how much he's willing to accept in payment for his services. They'd be able to talk directly to their doctor about pre-arranged fees for procedures, especially if they had no insurance. They'd have a way to negotiate with a hospital and show them the costs at other hospitals in the area. They'd also know what a hospital room, or ICU room, or operating-room-by-the-minute or Tylenol costs. And if they didn't want to pay the cost of a Tylenol, they'd be able to bring their own. But you see, that would not allow the hospital to pay for the electricity, and janitors, and cooking staff, and security force, and hoards of quality assurance coordinators and data gatherers.

Here's the newsflash: most Big Corporations are the "consumers." They buy insurance policies for many, many, many individuals. They're whom the financial and insurance industry lends an ear, not the individual patients themselves (although this might be changing slowly as more people aren't insured). And this Big Business "Consumer-Driven Healthcare" bus is being driven into your living room and computer console without a shred of evidence that it impacts (on a large scale) where patients receive their care. Here's the deal: most people go to the hospital facility closest to them. Period. They want to be near friends and family.

So all this marketing hype about "consumer-driven healthcare" means nothing - especially if you're going to try to figure out what it's going to cost you (versus your insurer) for a particular medical service. Like some asinine $5.2 million dollar website is going to make that happen?

Now I'm not saying that all the information on the web is necessarily bad. On the contrary. I firmly believe that the information on the web is helpful - even lifesaving - on occasion (can you say "Dr. Google?") Heck, just this week a neighbor of mine gradually had increasing right lower quadrant discomfort and Googled their symptoms and it suggested "appendicitis" - the correct diagnosis - prompting this individual to seek ER evaluation early. Forums and web-based support groups also can be remarkably helpful on a whole other level: they're the power of community.

But I only need to look at myself and the difficulty I have in determining who is a good doctor or a fantastic doctor, and realize even I - one working every day in the healthcare world - have a tough time telling who's okay, good, or great. That's because I don't work with dermatologists every day, or neurologists, or pathologists, or oncologists, or pulmonologists or urologists. Now I can tell you who'd I recommend as a reasonable internist (since I work with them more often), but most of them might not go to the hospital anymore, so how good is that recommendation, eh? You'll probably get whatever hospitalist is covering the ward that week when you come in sick. Good luck finding that person's credentials or being able to pick who's covering. And nursing coverage? You know, that all-important nurse-to-patient ratio that determines the real quality of care? Since your likely to know which ward you'll be admitted to, that information is irrelevant too.

Yep - the "consumer-driven healthcare" movement: leaving little to impact your real medical care (except a really cool website).

All for a cool $5.2 million bucks and counting.

-Wes

h/t: Wall Street Journal Health Blog

Image reference.

News Stereotaxis Doesn't Need

More challenges for Stereotaxis were reported today in the St. Louis Post-Dispatch. I find it interesting that it now costs an additional $400,000 to "simplify" the computer interface with this system.

With the underlying infrastructure and construction costs above and beyond the system price, they might want to consider dropping the price to improve sales instead of raising it.

-Wes

MacGyver Moments in Medicine

I love MacGyver moments in medicine. You know, those time when you're stuck in a predicament with a sick patient and have to come up with a creative way to get out of a jam. I had mine this week.

It was an elderly patient, but not too old, with recurrent incessant ventricular tachycardia and a very weak heart muscle. The rhythms were repetitive, and it was clear there was more than one morphology of the ventricular tachycardia was noted on EKG's obtained. Amiodarone, lidocaine, procainamide, beta blockers and even general anesthesia were all ineffective at stopping the rhythm, but helped slow the rhythm. She was taken for a catheter ablation, but this too was unsuccessful at finding the dominant VT - even after working on it for over eight hours, for this was not just ANY ventricular tachycardia - this was a ventricular tachycardia that was not reentrant, but triggered. And despite our best efforts, we could not figure out what the heck it took to trigger it so we could map and ablate it.

It was an ugly situation. Simply ugly.

So what better time to turn to MacGyver, that cool, calm secret agent who made his contraptions on the fly to get him out of the most difficult of circumstances. After all, if MacGyver can use two candlestick holders, a floor mat, and an electrical power cord as a makeshift defibrillator to revive a fallen comrade, he can do just about anything.

My problem was this: I had a lady with recurrent ventricular tachycardia in whom medications and ablation didn't work and in whom a defibrillator would be contraindicated if it meant she'd receive recurrent ICD firings. It was impossible to provoke her arrhythmia to see if we could even pace-terminate it. So what to do?

Well, first, I elected to leave a temporary pacing wire in her heart. Maybe, just maybe, we could overdrive pace the rhythm with an external pacer, rather than leaving her in minutes of VT or having to shock her while we treated her heart failure.

It was worth a try.

But it soon became apparent that the rapid ventricular tachycardia rate did not lend itself to an adequate comfort zone for the ICU staff to attempt pace-termination. Somehow turning on ventricular pacing at 180 b/min for a few seconds was just too nerve-wracking for the nurses and housestaff to perform reliably, and was not always effective - possibly because of the hesitancy to pace the ventricle that fast.

Implantable cardiac defibrillators have different ways to pace-terminate a rhythm - they can "burst pace" a rhythm at a certain percentage of the tachycardia cycle length for, say, eight beats at a set rate, or they can "ramp-pace" - that is, pace the rhythm with eight successively shorter beats. These pacing algorithms also respond very quickly to the arrhythmia - in seconds.

"If I could just use the algorithms in an ICD to pace her heart," I thought.

And then I had an idea. Could I connect the temporary pacing wire to an ICD? I had an old explanted one in our lab. Maybe I could use it? But the small ports where the leads plug in are difficult to access. The connections are housed inside the header of the device, shown below:



And somehow I had to attach the ICD to a pacing cable that would connect to the temporary wire, seen here:


So I took an old lead adapter that split from the "IS-1" pin connector used inside the defibrillator to two terminals and shoved some old defibrillator patch wires inside and tightened the little securing hex nuts and suturing the cable to the adapter with a little silk suture, shown here:


Then, it was just a matter of a bit of splicing and taping:


Then it just got all connected together to make a antitachycardia pacing device that could be connected to the patient's temporary pacing wire:



And the cool thing is...

... it worked like a charm: 100% pace-termination with ramp pacing at 84% of the VT cycle length within seconds.

Anyone else have such a moment?

-Wes

Healthcare: The Next Bubble?

Imagine, medical conventions are now the prized catch of the convention industry:

"Medical events have attracted long-staying, high-spending visitors … so everybody wants them, and any number of cities, including San Diego, New Orleans, Boston and Chicago have proclaimed themselves to be the natural home of such meetings."

"Whether there is enough business to go around is a seriously open question, especially with the market overbuilt as it is," Sanders said.

Chicago's newly opened $882 million McCormick Place West Building is among the facilities aiming to attract a bigger slice of the medical meeting business. So far, its sales force doesn't appear concerned about the Cleveland project.

"The competition across this industry is fierce," acknowledged Meghan Risch, a spokeswoman for the Chicago Convention and Tourism Bureau, which books the hall. "But we're not going to speculate on a project that, up to this point, doesn't have a design plan, tenants or even the ability to book future business."

Chicago was the No. 2 site for medical meetings in the U.S., behind Las Vegas, in 2006, according to the most recent data posted by the Healthcare Convention Exhibitors Association. Cleveland, which has an outdated, underutilized convention center, did not make the association's list of the top 20 host cities.

Still in early planning stages, the Cleveland project is expected to cost about $400 million, with the county picking up most of the tab, and will include 100,000 square feet of showroom space, 300,000 square feet of trade show space and a conference center. A downtown Cleveland location is expected to be selected this summer. One front-runner site is owned by Forest City Enterprises, the Cleveland-based co-developer of the Central Station mixed-use project in Chicago's South Loop.

Increasingly, our economy has become dependent on healthcare as its economic engine:

"Fifty thousand people in a population of 1.3 million (in Cleveland) work in the medical industry, so it's now the GM of an old industrial community," said Timothy Hagan, a county commissioner. The three county commissioners approved a sales tax increase to finance the project.

And despite the glut of convention space nationally and with Medicare looking at financial insolvency in the not-so-distant future, we are left to wonder...

... will healthcare be the next bubble to pop?

-Wes

EKG Du Jour - #6

Yet another fast and furious EKG Du Jour from the EKG Hall of Shame Fame:

This time, it's a 39 year old who presents from her internist's office after complaining of a 19-year history of palpitations which occur very sporatically. She had been seen by a cardiologist previously who workup was unrevealing: no family history of sudden death or heart disease, normal physical examination, "normal EKG" and "normal echo" (except for "flattening of her mitral valve on parasternal long axis view"). She was labeled as having "probable mitral valve prolapse" and administered Atenolol 25 mg daily, without effect. You, the ever-capable EKG aficionado, obtain this EKG:

Click image to enlarge

You smile, for the answer lies within. What do you tell her?

-Wes

Zombie Housestaff

Imagine, a hospital administrator's dream come true:

No more handwashing.

No more spread of MRSA.

No more spread of Clostridium dificile.

No need to even touch the patient!

And all for only four to seven thousand dollars a month as operating salary with no more malpractice insurance payments.

Residents and doctors never have to leave the friendly confines of their desk as they sit before the Almighty Electronic Medical Record nor expose themselves to unseemly odors.

What is it?

Welcome to the new world of Zombie Housestaff.

It won't be long 'til they place appendages carrying stethoscopes, thermometers, blood presure cuffs, EKG stickers and pulse oximeter probes complete with operational diagrams for the patient. It will be the ultimate in patient empowerment!

But there remains one question: will it come with a cup holder?

-Wes

Our Finest Olympiads

I wish the Olympic Games in Beijing would emulate this spirit.

-Wes

The "Hidden Curriculum"

From the Chicago Tribune today:

Indoctrination into the finer points of slang is part of what many professors call the hidden curriculum of medical school and residency training. The official course work requires reading textbooks and paying attention during medical rounds, but the rest comes from watching how older doctors and nurses actually deal with the sometimes overwhelming experience of caring for patients.

A common slip happens when doctors refer to a patient as his or her disease—as in, "the gall bladder in Room 602" or "the P.E. [short for pulmonary embolism] who was admitted last night."

Gregory Makoul, director of Northwestern's center for communication and medicine, said such references can make doctors forget the human dimension of their decisions.

"When you start labeling someone as a disease you can't help but see them as a problem and not as a person," Makoul said. "We try to get people to recognize that, the power and detriment of that sort of label."

Some residents note that medical privacy regulations have made doctors and nurses careful about when they use a patient's name, which can encourage shorthand such as referring to patients by their disease.

Many medical slang terms revolve around the struggle to get patients in and out of the hospital as fast as possible. Schumann said such concerns reached new heights in the 1980s, when Medicare and many insurance plans began paying hospitals fixed rates according to a patient's illness, putting a premium on wrapping up care quickly.

Things haven't changed in the 2000's either. Personally, I really don't like when staff call a patient by their room number, but I can certainly see, with the quick turn-arounds due to business pressures, "right side, right surgery, right patient initiatives" and privacy implications of our work, why this happens.

Of course, there's the issue of new-onset "CRS:" also known as "can't remember (uh) stuff." In those cases, I occasionally ask my staff how good ol' Ms. Fatchamatacheesedip is doing. They usually can figure it out and it seems so much more personal that way...

-Wes

Grand Rounds is Up

... and there's some great writing over at Suture for a Living:

I had no theme for this Grand Rounds, but thought I would share some links and photos of Arkansas.

A humble beginning for a great edition.

-Wes

You Know You're Getting Old When...

... you find yourself making two sets of rounds in the hospital:

One for work rounds, seeing patients.

And one for social rounds, seeing friends.

This week, my social round census began to approach my work census. Hope you guys get better soon!

-Wes