A Letter to Congress: Let Us Help You

Dear Congress:

I wanted to write you to tell you how proud I am of you. You’ve worked so hard on health care reform and focusing on what matters to Americans. Your beautifully conducted Health Care Summit, live before the C-SPAN cameras (finally) was a welcomed site. I have such a better grasp of the issues now. Thank you. You folks are awesome.

I did notice that both sides seem to be entrenched over what to do going forward – at least on camera. Everyone wants everyone to have insurance, but that thorny issue of costs keeps raising its head. Dog gone it. There always seems to be something to serve as a spoiler when real discussions take place in this health care reform debate.

But take heart. There is a way to fix all of the problems encountered with health care reform and I think you know what that the answer is: cut the doctor’s Medicare payments, already only 80% of costs, by another 21%.

We, your ever-ready and willing sycophants think that’s a great idea.

Knowing that we can be “team players” that are willing to take a leading role in health care reform will finally cement our image as omni-beneficent. People will finally be able to see through the media stories (transcript) that aired the day before the Health Care Summit about doctors as sexual predators. (video here). As Rahm Emmanuel said, “"You never want a serious crisis to go to waste. And what I mean by that is an opportunity to do things you think you could not do before." We as physicians are happy to do our part to counter these "systemic" problems with doctors. Thank you.

Now just so you know, we might have to make some eentsy–teensy–weentsy adjustments to how we do things, but it’s all be good. Really. Don’t worry. We’re innovators and entrepreneurs after all. We’ll figure out a way to curb inflation. We’ll lower the costs of staffing and equipment. And we’ll even single-handedly take ourselves off your payroll to lighten your load.

And it will all be good.

I mean, what could go wrong?

-Wes

Don't Abandon Manual Blood Pressure Cuffs

... they might help preserve myocardium:

333 consecutive adult patients with a suspected first acute myocardial infarction were randomly assigned in a 1:1 ratio by computerised block randomisation to receive primary percutaneous coronary intervention with (n=166 patients) versus without (n=167) remote conditioning (intermittent arm ischaemia through four cycles of 5-min inflation and 5-min deflation of a blood-pressure cuff). Allocation was concealed with opaque sealed envelopes. Patients received remote conditioning during transport to hospital, and primary percutaneous coronary intervention in hospital. The primary endpoint was myocardial salvage index at 30 days after primary percutaneous coronary intervention, measured by myocardial perfusion imaging as the proportion of the area at risk salvaged by treatment; analysis was per protocol.

...

Median salvage index was 0·75 (IQR 0·50—0·93, n=73) in the remote conditioning group versus 0·55 (0·35—0·88, n=69) in the control group, with median difference of 0·10 (95% CI 0·01—0·22; p=0·0333); mean salvage index was 0·69 (SD 0·27) versus 0·57 (0·26), with mean difference of 0·12 (95% CI 0·01—0·21; p=0·0333).

Interpretation
Remote ischaemic conditioning before hospital admission increases myocardial salvage, and has a favourable safety profile. Our findings merit a larger trial to establish the effect of remote conditioning on clinical outcomes.

Hey, lose blood flow to an arm to save a heart. Works for me.

-Wes

Reference:
Bøtker HE at al. "Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomised trial" Lancet 27 February 2010 375: 727-734.

Live Blogging the ACC.10 Meeting

It's official.

I've been asked by the ACC to help live blog portions of the ACC.10, i2 Summit in Atlanta March 14-16, 2010 that includes a Health Information Technology spotlight session.

There will also be a lively session entitled “U.S. Health System Reform: Where are we headed?” on Sunday, March 14 from 12:15 to 1:45 p.m. with both sides of the political aisle represented by Chris Jennings, Deputy Assistant to the President for Health Care Policy and Congressman Paul D. Ryan Jr. (R-Wis.). No doubt it will be as productive as yesterday's White House Health Care Summit.

There will also be a session on insights into the tort reform controversy from Richard Anderson, M.D., CEO of The Doctors Company. Trial lawyers are particularly invited to this session (I need news, after all!)

Needless to say, while electrophysiology remains my passion, I'll see if there's some new gadget, gizmo, controversy or cardiovascular policy issue that stretches beyond the typical fray.

You can follow the posts on this blog or via Twitter (@doctorwes).

For full disclosure, the ACC is paying my registration fee, but transportation and housing are on me. I am NOT industry sponsored for this event and the ACC only asks that I refrain from using four-letter words.

I'll try.

-Wes

Could a Boob Job Save Your Life?

Don't count on it, but it sure makes for one heck of a story:

When a gunman stormed a Simi Valley dental office last summer and shot Lydia Carranza in the chest, salvation may have come in the shape of her size-D breast implant.

That's the theory at least of a Beverly Hills cosmetic surgeon who hopes to drum up support to defray the costs of Carranza's reconstructive surgery.

"She's just one lucky woman," said Dr. Ashkan Ghavami, who says he will perform the surgery for next to nothing but has urged Carranza to tell her story in hopes of getting implant companies to donate the supplies.

Ghavami contends that the implant absorbed much of the bullet's impact, limiting most of the damage to the breast itself.

"I saw the CT scan," he said. "The bullet fragments were millimeters from her heart and her vital organs. Had she not had the implant, she might not be alive today."

The hospital where Carranza was treated is not prepared to make that call.

"This is not a medical issue; it's a ballistic issue," said Kris Carraway, a spokeswoman for Los Robles Hospital & Medical Center in Thousand Oaks. "The emergency physician who treated the patient was not aware of the breast implant having any impact or whether or not it saved her life."

But Scott Reitz, a firearms instructor and deadly-force expert witness with 30 years' experience in the LAPD, said that, although he was not involved in the case, the scenario Ghavami describes is entirely plausible.

"Common sense would dictate that any time you have something that interrupts the velocity of the projectile, it would benefit the object it was trying to strike," he said. And because a saline implant is like a high-pressure bag full of salt water, it probably would provide more resistance than plain flesh, he said.

"I don't want to say a boob job is the equivalent of a bulletproof vest," he added. "So don't go getting breast enhancements as a means to deflect a possible incoming bullet."

Sounds like wise advice and I knew you needed to know this.

-Wes

Blogging from Haiti

Dr. Mike Howard - one of our plastic surgeons, is live-blogging from Haiti. Here's a sample:

Looking at the historical course of cases here has been quite interesting. The quake occured on 12 January. Most amputees relate their first operation was not until 19, 20 or 21 January. Most ex-fixes went on between 22 Jan and 3 Feb. There will be a huge need here in 3-4 weeks just taking off exfixes. The scene is bad now 6 weeks out; I cant imagine the traumatic, mangled extremity scene the first week post quake. Thousands of crushes untreated for days.

Many of our current surgical cases are dealing with complications of prior surgeries. It is at first tempting to say "what were they thinking, doing that?" But, stepping back, imagining the scene and realizing that there was no way of knowing if they or the patient would ever get another chance. It was essentially 4 weeks of damage control surgery. It is amazing that the first groups in, did so much, so well. For the most part.

Case in point: one of my wound patients was admitted, seizing, 4 weeks ago (about 14 days post quake). In the ER, Dr. Ken was about to give him some ativan when a nurse injected the contents of another syringe into the patient. Penicillin. The guy survived his full blown tetnus (Ed's note: types like me) episode and looks great.

And from Wednesday's post:

Got an email last pm from a friend saying, "wow, it must be depressing."

Quite the opposite.

Yes, there is an amazing amt of destruction. The death toll is staggering. The poverty is everywhere. People living in the streets with nowhere to go or tents in front of their houses, afraid to go back inside. Corruption rivaling that of Chicago - maybe worse. The trauma fresh on the peoples faces and bodies. A generation of amputees in a country with zero handicap accessibility.

But, in the midst of all that, the sun is shining beautifully, the orphans at our hospital are truely smiling. The Haitian people are so friendly and appreciative. The volunteers are coming from everywhere, some alone, some by the bus load.

Health care doesn't get better than this. Nice work, Mike.

-Wes

Occupational Sciatica

Ever note lower back pain that radiates down your leg after standing at a cath lab or operating room table?

Timothy Sanborn, MD, director of cardiology at our institution shared his experience with this occupational hazard in a recent editorial (pdf) from Catheterization and Cardiovascular Interventions and offers an interesting non-invasive remedy short of laminectomy: hyperextension of the lower back using McKenzie exercises (video).

It's helped him.

-Wes

Putting the Cart Before the Horse

As Congress and their sycophants bicker over their current industry-sponsored 2,700-page health care bill and promise to save costs by continually bitch-slapping their physician workforce, perhaps they should consider these data:

Our findings are consistent with the possibility that economic factors such as lower fees and increased market pressure on physicians may have contributed, at least in part, to the recent decrease in physician hours. Further reductions in fees and increased market pressure on physicians may, therefore, contribute to continued decreases in physician work hours in the future.

Whatever the underlying cause, the decrease in mean hours worked among US physicians during the last decade raises implications for physician workforce supply and overall health care policy. A 5.7% decrease in hours worked by nonresident physicians in patient care, out of a workforce of approximately 630 000 in 2007, is equivalent to a loss of approximately 36 000 physicians from the workforce, had hours worked per physician not changed. Although the number of physicians has nearly doubled during the last 30 years, many workforce analysts and professional organizations are concerned about the adequacy of the size of the future physician workforce. This trend toward lower hours, if it continues, will make expanding or maintaining current levels of physician supply more difficult, although increases in the number of practicing physicians either through increases in the size of domestic medical school classes (ed's note: expensive option) or further immigration of international medical graduates (ed's note: cheap option) would mitigate those concerns. Moreover, if this trend toward lower physician hours continues, it could frustrate stated goals of health reform, which may require an expanded physician workforce to take on new roles and enhanced functions (ed's note: as nurse managers and transcriptionists) in a reformed delivery system.

Yep, I'm seeing nothing but good things ahead if the current health bill before Congress is passed.

-Wes

Staiger DO, Auerbach DI, Buerhaus PI. "Trends in the Work Hours of Physicians in the United States" JAMA. 2010;303(8):747-753.

Medicine's Infinite Variety

He was a pleasant, elderly man with an automatic defibrillator installed many years ago who unfortunately developed atrial fibrillation with rapid ventricular response that coincided with the same rates as his slow ventricular tachycardia, resulting in shocks from his ICD that he really preferred not to have. But he also was plagued by a more concerning problem (as far as the family was concerned) that had grown worse over the years: dementia.

I had explained the pros and cons of AV junctional ablation in great detail to him and is faily members in great detail the night before and all agreed this was the best course of action. His wife co-signed the consent. Everything was set. He was brought down to the holding area before his procedure with the family members beside him. As is customary, I greeted them before the procedure and turned to him to ask if he was ready and if he had any further questions.

Smiling, he said: "Nope, but that stuff you pour on those stumps sure works great - gets rid of the roots and all."

And that, in a nutshell, is why I love my job.

-Wes

Another Medicare Billing Blunder

Yes folks, doctors' Medicare payments are in the best of hands:

If your heart skipped a beat when you saw that January’s Correct Coding Initiative (CCI) edits bundled catheter ablations with electrophysiology (EP) studies, you weren’t alone.

Good news: CMS has decided to delete the edits retroactively because their addition was a mistake, according to the Heart Rhythm Society (HRS).

Snag: The deletion won’t happen until April 1.

Interesting that Uncle Sam can charge interest to you if you don't pay your taxes on time, but we can't charge Uncle Sam interest when we don't receive our payments on time.

-Wes

A Stethoscope App for the iPhone

It's out there. It makes a cool picture, but I wonder how many medical students realize how unimportant apps like this have become to today's cardiovascular care. Don't get me wrong, it's good to hear the difference between a systolic and diastolic murmur, or for the really talented, a diastolic rumble on physical exam. Recognizing the difference between mild and severe aortic stenosis is also very helpful. After all, the physical exam remains the most cost-effective instrument in medicine.

But graphics to show the murmur that requires an electronic stethoscope and preamplifier to connect them to your iPhone? How much money do you want to waste on these toys?

The best way I know how to learn is get off the computer and get to the bedside. Look, listen, and feel the precordium a thousand times over. Only by doing will you learn. You really don't need an expensive stethoscope (but it does helps the auditorially challenged). I admit that I've stopped using super-expensive stethoscopes because I always lose them when I change into scrubs or round on too many different wards (or they're often stolen).

Honestly, by the time I'm asked to see a patient, the echocardiogram is already done, so for me, listening to the lung sounds and measuring blood pressures (especially orthostatics for patients with syncope) remains the most important reason I still carry (or borrow) an the old, cheesy, analog version of the stethoscope.

-Wes

h/t: Dr. Joseph Kim via Twitter.

Antiviral "Boosting" Boosts Arrhythmia Risk

The FDA issued this press release today regarding several antivirals used in combination to treat HIV that can cause pro-arrhythmia by prolonging the QT interval on the EKG:

Invirase (saquinavir) and Norvir (ritonavir) are antiviral medications given together to treat HIV infection. Norvir is given at a low dose with Invirase in order to increase the level of Invirase in the body. This is a process known as "boosting."

FDA's analysis of these data is ongoing. However, healthcare professionals should be aware of this potential risk for changes to the electrical activity of the heart. Invirase and Norvir should not be used in patients already taking medications known to cause QT interval prolongation such as Class IA (such as quinidine,) or Class III (such as amiodarone) antiarrhythmic drugs; or in patients with a history of QT interval prolongation.

Patients should not stop taking their prescribed antiviral medications. Patients who are concerned about possible risks associated with using Invirase and Norvir should talk to their healthcare professional.

I like the last line: "...talk to their healthcare professional."

What that really means is that if you're on these two medications, you should get an EKG right away to see if your QT interval is prolonged. If it is, your doctor will have to decide which (if any) drug might need to have its dose adjusted or be stopped.

This problem is a common one in patients on many different medications that can interact and cause QT interval prolongation on the EKG and these antivirals need to be added to a long list of other medications. QTDrugs.org has a fairly comprehensive listing of them.

Be careful out there...

-Wes

JACC to Appear on the Kindle

This Christmas, I bought my wife, an unmitigated book-lover, a new Kindle 2 from Amazon. While she's a bit of a Luddite when it comes to technology, she has quickly become a believer - uploading three books at a time to bring with her on weekend trips. (She's even one of my three subscribers to this blog on the Kindle!) My only regret is hearing the soft "*click* ... (pause) ... *click*" in bed as she turns electronic pages at bedtime.

While hard copy books will still be great permanent reference sources, the plethora of fast-moving printed journals seem ripe for electronic disruption. I wouldn't be surprised to find that most journals as we know them eventually go the way of the dinosaur. As proof comes this from the ACC:

The Journal of the American College of Cardiology (JACC) will be available on the Amazon Kindle e-book reading device starting this March. JACC is the first cardiovascular journal on the Kindle platform and the second medical journal after the New England Journal of Medicine. Visit the Kindle store on amazon.com beginning on March 12 to order and learn more. Also, bring Kindle to ACC.10 in Atlanta to download the meeting abstracts and final program.

Welcome to the 21st Century!

-Wes

Dick vs. Bill

Bill Clinton gets chest pain, hits the hospital, gets a few stents and, voilà, is back at work. A veritable poster child for stents. No doubt JNJ stock climbed on the news.

On the flip side today: Dick Cheney gets chest pain, hits the hospital, and (I'll bet) he stays a while.

What do you mean, Dr. Wes? Can't cardiologist magically fix everything? Do a cath! Give him a stent! Cardiology is so slam bam thank you ma'am, isn't it? Heck, he's got an ICD! He's the bionic man!

Cardiology is easy until it isn't.

No doubt Mr. Cheney has had impecable cardiovacular care. But despite that care, after three bypasses, a history of atrial fibrillation, deep venous thrombosis, a cardiomyopathy that requires a defibrillator or two, and scores of medications to stabilize the angina - you've suddenly got a tough case. One thing's for sure, a re-do bypass is pretty much out of the question (he probably has limited vascular conduits left to borrow).

For the treating cardiologists hoping for an obvious target to angioplasty, I wouldn't be surprised the "target" vessel will not be so obvious to determine after his angiogram today. Look for a nuclear scan tomorrow to figure which wall of his heart is affected (yes, Congress, he'll get one of those all-too-often ordered i-m-a-g-i-n-g studies!). Then look for either a risky angioplasty atempt to improve his symptoms or a (more appropriate) "tuning" of his medication regimen that will take time.

Bill vs. Dick: it's not about Democrats vs. Republicans. Rather, it's about the multifasceted care required of the same disease in two different patients that demonstrates nicely how health care for the individual will never be adequately managed through cookbook means.

-Wes

Name Alert! Treating PE

My entire medical career "PE" used to be about a pulmonary affliction where a blood clot goes to the lungs: pulmonary embolus. Now, thanks to the power of marketing gurus who have little regard for medical nomenclature, there's a new "PE" in town involving the same organ as the heavily marketed malady, "ED."

Sheesh.

Talk about the yin and yang of urology...

-Wes

Using Videos to Help Consent Patients

Consenting patients for complicated procedures like atrial fibrillation ablation takes considerable time to do well and our facility might do things very differently than other institutions. To assure patients heard a consistent message and to help facilitate our visits with them, we decided to create a 9-minute video to supplement our discussions during our procedural consenting process. While our video was professionally produced (and the circles around my eyes disclose the time of day this was shot), no doubt a simpler video using a hand-held HD video camera and iMovie software on a MAC could provide similar results at lower cost.

In general, I think our patients have appreciated that they can view the video online at home or here in our office as often as desired. We also have burned copies to a DVD so the video can be viewed on a DVD player at home. While the work cannot be completely comprehensive, doesn't have subtitles, and includes only a single patient testimonial, it assures that we convey salient points consistently about what the patient can expect before, during, and immediately after their ablation procedure. Needless to say, they still must sign our standard surgical consent form before undergoing their procedure.

Writing the script for this video forced all three electrophysiologists in our group to agree on the video's content - no easy task as each of us came to this procedure with minor biases as to what were the most important aspects to convey - but this exercise helped us focus our message. Our ongoing challenge will be to update the video as new innovations or information become available in this fast-moving field.

We are not the first ones to use video consenting. Similar efforts have been a common theme in research, such as HIV, neurologic stimulation or chemotherapeutic studies. One trial in performed before arthroscopic procedures showed improved comprehension of information with video compared to standard consent forms. It is also interesting to note that there is an NIMH trial underway to study video consenting in patients with mental illness compared to standard methods.

Important disclaimer: For those contemplating catheter ablation of atrial fibrillation, this video might prove helpful to improve general understanding of the procedure but should not be construed as representative of how other centers perform the procedure nor as a comprehensive list of all of the risks, benefits, or alternative therapies involved in treating atrial fibrillation.

-Wes

Image reference: Jason Wolfe.

True Confession

I came across this picture of my desk just before we went "all in" with our electronic medical record six years ago:



It was a huge amount of work for our staff to organize and box all those old medical records that were sent off to a site unknown. I remember early on when we tried to get some old records after that happened. People just shrugged - no one had a clue how to retrieve them.

But you know what?

Now that we're farther away from that time, I can't say that I miss them.

Still, my current desk looks just as disorganized.

-Wes

Swiss Call Girls Offer Full Cardiovascular Services

... all in the name of satisfied customers who will hopefully live long enough to assure payment:

Prostitutes in the picturesque Swiss lakeside town of Lugano are adding defibrillation to their list of services following the death of several elderly punters whose hearts just couldn't take the pace.

According to the Corriere della Sera, there are currently 38 brothels and sex clubs in the Lugano area, and more are planned to accommodate the rising tide of customers who pop over the border from Italy.

For some, though, this proves to be a day trip too far. The most recent case was a pensioner who suffered a heart attack while enjoying Lugano's delights with the aid of "pharmaceutical assistance".

Looks like we've done a good job getting the message out on the benefits of automatic external defibrillators...

-Wes

h/t: @rlbates via Twitter.

How to Bring Health Care to Its Knees

... just infect hospital electronic medical record (EMR) systems with a worm:

Computer systems at the West Middlesex University Hospital NHS Trust were infected by the worm last Friday, leaving hospital staff unable to book appointments via computer. The outbreak has been contained but some hospital IT systems remain unavailable, resulting in ongoing delays to patients and affecting the smooth running of the medical facility.

A hospital spokeswoman told El Reg that the malware infection, identified as the Conficker-A, struck on Friday afternoon. "Most of the computers had to be cleaned, so we've had to rely on a pen and paper system to book appointments. Technicians worked over the weekend to clean up systems. Priority systems are running but the clean-up is likely to last until the end of the week."

The really scary thing is, today's medical personnel (newer doctors, nurses, residents, medical students, secretaries, lab technicians - the whole works) have no clue how to work a paper-based medical record any longer. Worse, there's no regular contingency plan in place should an EMR crash for over an hour.

But no worries, it'll never happen.

-Wes

Using Cow Manure to Say I Love You

Nothing says I love you like a pile of... well, cow manure (video).

If nothing else, you have to admire this farmer's creativity...

-Wes

Pacemakers and Defibrillators in the Dental Chair

Powerful magnets that can interfere with pacemakers and defibrillators can pop up in the strangest places, like dental chair headrests:

A few months ago, Boston Scientific, one of the major manufacturers of pacemakers/ICDs, added a new caution to their contraindications for dental patients. They warn that if a patient has a pacemaker/ICD, and the dental chair has a magnetic headrest with strength over 10 gauss, the patient should NOT sit in the chair.

The company states: “Some dental chairs contain magnets located in the headrest. If the pacemaker or defibrillator is programmed not to respond to a magnet, patients may sit in these chairs. If the implanted device is programmed to respond to a magnet and the magnet power is less than 10 gauss, patients may sit in these chairs. If the magnet power is greater than or equal to 10 gauss, patients should not sit in these chairs as the device function/programming may be affected.”

Allow me to explain. Magnet strength is measured in gauss units. The farther the distance from the magnet, the weaker the gauss reading, which means a weaker magnetic field. The magnets on dental chairs currently in use contain magnets with strength over 400 gauss. (Strengths vary slightly among manufacturers.) Therefore, sitting in the typical dental chair with a pacemaker/ICD, one would have to be five to six inches away from the magnet to be safe. Sometimes, however, dental professionals have trouble accessing certain parts of the mouth, and we ask patients to move up in the headrest, which is closer to the magnet. When we get too close to the magnet, the magnetic effect increases, and therefore, so does the potential for complications.

The linked article above does a good job giving a balanced review of this topic, so take a minute to read the whole thing.

-Wes

Reference: Boston Scientific's "Dental Equipment and Implantable Pacemakers and Defibrillators" white paper dated 2 Feb 2009.