it's Game day, that day when the whOle world will sit and watch the super bowl between the chicago BEARS and indianapolis colts. we are fortunate to have the opportunity to share the best of sport today. so as you GO to friend's house and sit to watch the BEARS vs. colts, remember: may the BEst teAm Realize Success!
not that i'm biased, or anything.
-Wes
with apologies to e.e. cummings
Sunday, February 04, 2007
Friday, February 02, 2007
The Indoctrination
It was a cold day, many, many years ago. A young, impressionable medical student entered the VA hospital on his first day of his medicine rotation. Never before had he seen so many patients, nurses, doctors, family members hurrying to get to their destinations. No one was smiling.
The hospital was of the 1950’s genre: tall, foreboding and quite intimidating for the young medical intern. The layout of the building was idiotic, with two large elevators centrally located that carried the patients between their rooms and testing facilities. Like a 90-percent stenosis of the left anterior descending artery, all patient traffic flowed through these elevators and the traffic in turn, moved slowly. Hoards of patients, nurses, doctors and family members waited for the elevator and would enter whether it went up or down, because to get on the elevator meant at least you were sure to get to your destination, eventually.
No one knew this better than the seasoned patient transport personnel. Their days were made or broken by the ability to move patients from one point to another. The impressionable medical student spied one of these transporters as he entered the main corridor of the hospital. There she was, Ms. B., pushing a thin, confused man in his 80’s covered with four hospital gowns left untied from his recent testing, his foley catheter draped from the side-arm of the chair, his IV draped over Ms. B’s shoulder.
“Alright, Mr. J, we’ve gotta get yous on one of these elevators to get you back to yo’ room.”
She stood before the bank of elevators, waiting restlessly.
“Damn, you think they’re ever gonna come?”
“Hopefully soon, ma’am,” said the medical student.
They waited and waited. Finally an elevator door opened. No one got out. They waited, and the door closed and the elevator returned to the upper floors.
“Shheeeeaaatttt,” said Ms. B. “You hang on Mr. J. I’m gonna get you on that next elevator if it kills me!”
Again she and Mr. J waited. The medical student looked on, realizing he’d better not take any space on the elevator before Ms. B and Mr. J.
Finally, the other elevator door opened packed with people. Four people left, three more got on before Ms. B. She knew this was her chance.
She swiveled Mr. J around and backed her generous derrière back into the packed elevator, towing Mr. J’s wheelchair, too. The door began to close and hit the side rail of Mr. J’s wheelchair as she struggled to compress the impeding crowd of people on the elevator and negotiate the wheelchair into the elevator car.
“Com’on ya’ll, let us sick folks in!” she shouted as she shoved.
“Bang,” went the elevator door. She shoved harder. “Bang,” the door tried to shut again. She made a few more inches. “Bang,” the door hit the foot rests of Mr. J’s wheelchair. She gave one final shove and cleared the door. The elevator door closed.
But unbeknownst to Ms. B and Mr. J, Mr. J’s foley bag had fallen to the floor and had not cleared the door.
A bewildered medical student looked on as the foley bag flew up from the ground. It struck the ceiling of the elevator door with such force that the foley bag disconnected from the tubing. Urine splashed all over the ground. Patients, nurses and physicians near the door scattered.
Finally, a seasoned attending physician munching on a bag of chips smiled. He leaned over to the bewildered intern and whispered:
“Welcome to Medicine.”
-Wes
The hospital was of the 1950’s genre: tall, foreboding and quite intimidating for the young medical intern. The layout of the building was idiotic, with two large elevators centrally located that carried the patients between their rooms and testing facilities. Like a 90-percent stenosis of the left anterior descending artery, all patient traffic flowed through these elevators and the traffic in turn, moved slowly. Hoards of patients, nurses, doctors and family members waited for the elevator and would enter whether it went up or down, because to get on the elevator meant at least you were sure to get to your destination, eventually.
No one knew this better than the seasoned patient transport personnel. Their days were made or broken by the ability to move patients from one point to another. The impressionable medical student spied one of these transporters as he entered the main corridor of the hospital. There she was, Ms. B., pushing a thin, confused man in his 80’s covered with four hospital gowns left untied from his recent testing, his foley catheter draped from the side-arm of the chair, his IV draped over Ms. B’s shoulder.
“Alright, Mr. J, we’ve gotta get yous on one of these elevators to get you back to yo’ room.”
She stood before the bank of elevators, waiting restlessly.
“Damn, you think they’re ever gonna come?”
“Hopefully soon, ma’am,” said the medical student.
They waited and waited. Finally an elevator door opened. No one got out. They waited, and the door closed and the elevator returned to the upper floors.
“Shheeeeaaatttt,” said Ms. B. “You hang on Mr. J. I’m gonna get you on that next elevator if it kills me!”
Again she and Mr. J waited. The medical student looked on, realizing he’d better not take any space on the elevator before Ms. B and Mr. J.
Finally, the other elevator door opened packed with people. Four people left, three more got on before Ms. B. She knew this was her chance.
She swiveled Mr. J around and backed her generous derrière back into the packed elevator, towing Mr. J’s wheelchair, too. The door began to close and hit the side rail of Mr. J’s wheelchair as she struggled to compress the impeding crowd of people on the elevator and negotiate the wheelchair into the elevator car.
“Com’on ya’ll, let us sick folks in!” she shouted as she shoved.
“Bang,” went the elevator door. She shoved harder. “Bang,” the door tried to shut again. She made a few more inches. “Bang,” the door hit the foot rests of Mr. J’s wheelchair. She gave one final shove and cleared the door. The elevator door closed.
But unbeknownst to Ms. B and Mr. J, Mr. J’s foley bag had fallen to the floor and had not cleared the door.
A bewildered medical student looked on as the foley bag flew up from the ground. It struck the ceiling of the elevator door with such force that the foley bag disconnected from the tubing. Urine splashed all over the ground. Patients, nurses and physicians near the door scattered.
Finally, a seasoned attending physician munching on a bag of chips smiled. He leaned over to the bewildered intern and whispered:
“Welcome to Medicine.”
-Wes
Video Games Peel the Pounds
Finally, a realistic approach to dealing with the obesity epidemic in America: video games.
And then there is the Wii from Nintendo, with its amazing controller that moves objects on the video screen in relation to the controller's movements. My daughter played their boxing game and had to give up in exhausion after ducking jabs from the animated opponent. Aside from the occassional flying controller that has lead to this funny video parody, these games are incredibly addictive (and fun) to play.
But West Virginia's program was not just about video games - dietary education supplemented their program as well. But the dietary education likely would have fallen on deaf ears had the video games not been used. Meeting kids on their turf and facilitating the improved sense of self by letting kids rediscover their "exercise self" in a fun, age-appropriate way certainly contributed to the success of this program.
Now the message needn't stop with kids. Imagine if employers had these installed in their workplace dining rooms across corporate America - it would be better than attending a Karaoke bar, wouldn't it? All those big folks bopping about, and all.
Now, if I could just get one installed in our lab between cases...
-Wes
(West Virginia), which plans to put the popular dancing video game in every one of its public schools, said on Wednesday research suggested that it helped put a halt to weight gain.Konami's "Dance Dance Revolution" is one such game where kids hop on an electronic mat and try to mimick moves displayed faster and faster on the video screen. It can be alone or socially with friends. It's a lot like electronic jump rope, but requires an amazing amount of stamina and coordination.
Preliminary results from a 24-week study of 50 overweight or obese children, aged 7 to 12, showed that those who played the game at home for at least 30 minutes five days per week maintained their weight and saw a reduction in some risk factors for heart disease and diabetes.
And then there is the Wii from Nintendo, with its amazing controller that moves objects on the video screen in relation to the controller's movements. My daughter played their boxing game and had to give up in exhausion after ducking jabs from the animated opponent. Aside from the occassional flying controller that has lead to this funny video parody, these games are incredibly addictive (and fun) to play.
But West Virginia's program was not just about video games - dietary education supplemented their program as well. But the dietary education likely would have fallen on deaf ears had the video games not been used. Meeting kids on their turf and facilitating the improved sense of self by letting kids rediscover their "exercise self" in a fun, age-appropriate way certainly contributed to the success of this program.
Now the message needn't stop with kids. Imagine if employers had these installed in their workplace dining rooms across corporate America - it would be better than attending a Karaoke bar, wouldn't it? All those big folks bopping about, and all.
Now, if I could just get one installed in our lab between cases...
-Wes
Wednesday, January 31, 2007
Medtronic Concerto Investigation Update
I called Dave Steinhaus, MD, Vice President and Medical Director of the Cardiac Rhythm Management Division at Medtronic yesterday regarding the Concerto allegation and he returned my call about 45 minutes ago. In summary, it seems there were a number of engineering concerns that their former engineer, Christopher Fuller, had regarding the wireless platform that Medtronic implemented for the Concerto device (and also pertains to their Virtuoso ICD). Some of these concerns were addressed, he said, but others were not felt to be of concern to whom he raised issue with at Medtronic. He confirmed that Mr. Fuller then chose to report his concerns to the FDA and a Minnesota senator. Dr. Steinhaus referred me to this news release from Reuters, claiming the FDA investigation is closed.
In essence, their stand at present is that this is a disgruntled employee, and that there has been no failures or complaints of any of their Concerto or Virtuoso implants to date, and they stand by its safety.
-Wes
Addendum: 1 Feb 2007 1845PM - Regarding the above claim from the Reuters press release that states: "Medtronic said it has had no reports of patient safety issues related to the wireless features of the device." I have checked and found one patient injury reported on the FDA Maude database from the Concerto device dated August 1, 2006 resulting in a patient injury. It can be viewed here. I was unable to see if other reports occurred in 2007. In no way should be construed as being related to Mr. Fuller's allegations, nor related to significant engineering issues with the device.
This one device malfunction in an estimated 11,000 implants is well below the prior reported average of 20.7 device malfunctions in 1000 implants noted by the prior report of the Heart Rhythm Society's Task Force of Device Performance Policies and Guidelines. - Wes
In essence, their stand at present is that this is a disgruntled employee, and that there has been no failures or complaints of any of their Concerto or Virtuoso implants to date, and they stand by its safety.
-Wes
Addendum: 1 Feb 2007 1845PM - Regarding the above claim from the Reuters press release that states: "Medtronic said it has had no reports of patient safety issues related to the wireless features of the device." I have checked and found one patient injury reported on the FDA Maude database from the Concerto device dated August 1, 2006 resulting in a patient injury. It can be viewed here. I was unable to see if other reports occurred in 2007. In no way should be construed as being related to Mr. Fuller's allegations, nor related to significant engineering issues with the device.
This one device malfunction in an estimated 11,000 implants is well below the prior reported average of 20.7 device malfunctions in 1000 implants noted by the prior report of the Heart Rhythm Society's Task Force of Device Performance Policies and Guidelines. - Wes
Pregnant Mom Gets Her Wish
Jennifer Gordon, the very pregnant mom who wanted to trade her belly for ad space in exchange for Super Bowl tickets, got her wish today. She earned two tickets from uBid.com on the 50-yard line in exchange for showing her belly before, during, and after the game.
Funny thing will be if she delivers before then. Will her shrunken belly then have the contracture, "U'bom?"
Best of luck to her and her husband... and Go Bears!
Funny thing will be if she delivers before then. Will her shrunken belly then have the contracture, "U'bom?"
Best of luck to her and her husband... and Go Bears!
War Zone
A very moving front-line assessment of the war in Iraq can be found over at The Thoughts of Artemis. It makes my rants seem trivial.
-Wes
-Wes
The Irony
The irony of cigarettes:
-Wes
09:54 CST - Addendum: Sadly, Altria's Board just approved the spin-off of Kraft. Wall Street will be even happier...
“Wall Street loves money. And cigarettes are money. You are clearly earning huge returns at the expense of people’s lives.”It's enough to make you sick.-Michael D. Hausfeld, a lawyer in a pending class-action lawsuit against tobacco companies * * *
“At times, as a tobacco investor or a tobacco analyst, it seems like an unending stream of negative news,” Mr. Adelman of Morgan Stanley said. “You hear about smoking bans, a new piece of legislation. You hear about criticism from the World Health Organization.
“And then lo and behold, manufacturers release their results,” he said. “And they are good.”
-Wes
09:54 CST - Addendum: Sadly, Altria's Board just approved the spin-off of Kraft. Wall Street will be even happier...
East vs. West
I wonder if I should turn my office into a spa.
It seems spas are now incorporating acupuncture, an age-old therapy from the Far East, and billing $90-150 for one "therapist" to place little needles in peoples' forehead and allowing them to relax. People are flocking to these places.
In Western medicine, we too sometimes place needles in people, but at slightly different places.
But according to the Medicare 2007 fee schedule for an established patient office visit (codes 99213, 99214, or 99215), we can only collect (on average) between $45 and $130 and have a lot more paperwork.
No wonder doctors are thinking more and more about spas...
... they're stressed.
- Wes
It seems spas are now incorporating acupuncture, an age-old therapy from the Far East, and billing $90-150 for one "therapist" to place little needles in peoples' forehead and allowing them to relax. People are flocking to these places.
In Western medicine, we too sometimes place needles in people, but at slightly different places.
But according to the Medicare 2007 fee schedule for an established patient office visit (codes 99213, 99214, or 99215), we can only collect (on average) between $45 and $130 and have a lot more paperwork.
No wonder doctors are thinking more and more about spas...
... they're stressed.
- Wes
Tuesday, January 30, 2007
Grand Rounds 3.19 Is Up
Check out Medical Bloggers' Grand Rounds 3.19 over at Envisioning 2.0. The topic this week: Consumer-Driven Health Care. A very worthwhile read, indeed.
Next week, Grand Rounds will be hosted by Dr. Couz over at Tales from the Emergency Room and Beyond.
-Wes
Next week, Grand Rounds will be hosted by Dr. Couz over at Tales from the Emergency Room and Beyond.
-Wes
Medtronic 's Wireless ICD Scrutinized
This morning the WSJ reported that allegations were raised by a former Medtronic engineer, Christopher Fuller, regarding their Concerto biventricular implantable defibrillator:
Boy, this gives a new meaning to Medtronic's ICD ad campaign, "What's Inside?"
-Wes
Reference: WSJ (subscription required)
Mr. Fuller, an engineer who had worked on the Concerto device, said he resigned from Medtronic in protest over what he terms "serious issues" regarding "how Medtronic evaluated the Concerto."We have implanted some of these devices and are unaware of issues to date with the exception of the wireless telemetery having interference issues with surgical xenon headlamps, but await a formal response from Medtronic and the FDA's evaluation.
Last year, Mr. Fuller contacted the FDA and the offices of the U.S. senators from Minnesota. In one letter to Republican Sen. Norm Coleman, Mr. Fuller wrote that the Concerto device's long-distance telemetry "exhibited instabilities in testing" and that Medtronic "has chosen to ignore the problem."
Medtronic spokesman Rob Clark said the company believes the frequency band used by doctors to monitor patients with the Concerto "is dedicated for these uses and we believe it's extremely stable. We have had no adverse events reported due to the wireless telemetry features of the devices."
Mr. Fuller contends that this instability can "prevent other circuits from behaving properly" and can lead to "excessive" battery depletion or can "burn up" other circuitry in the devices.
Boy, this gives a new meaning to Medtronic's ICD ad campaign, "What's Inside?"
-Wes
Reference: WSJ (subscription required)
Monday, January 29, 2007
Acceleration/Deceleration Injury...
...might be what one gets if they try this crazy hillbilly slingshot routine:
-Wes
via Conservative Grapevine
-Wes
via Conservative Grapevine
An Intravascular Implantable Defibrillator
Just received word via a press release that InnerPulse, Inc has received funding to begin preparation for eventual clinical trials of a fully intravascular cardiac defibrillator. The implications for the patient will be an invisible implant, placed probably by a transvenous route from a femoral approach (in the leg). The company was founded in 2003 and has just won significant financial backing from many of the "biggies" in the defibrillator market (Medtronic, Boston Scientific, and Greatbach, but also has signficant investor interest from Johnson and Johnson). Sketchy details about the device are provided by their website, but the concept is VERY interesting and can extend to conventional pacing as well. Whether the device might increase the risk for deep venous thrombosis remains to be seen. Look for more on this in upcoming electrophysiology and interventional cardiology meetings.
-Wes
-Wes
Stretching Ethical Boundaries
Today's Chicago Tribune described an Israeli mother's desire to preserve her son's lineage:
- Wes
More than four years after her 20-year-old son was killed in action in the Gaza Strip, Rachel Cohen is hoping for a grandchild after winning a court case to have a woman inseminated with the dead soldier's sperm.The circumstances of the case have significant implications:
The case, decided this month by a court near Tel Aviv, is the first in the world in which a court permitted a woman to be inseminated from a known, dead sperm donor who was not her partner, according to the lawyer who argued the case, Irit Rosenblum.
Rosenblum, who heads New Family, an Israeli family rights group, said the ruling meant that family lines could continue years after death through a person unknown to the deceased.But what would the son have thought about this:
"We've created a victory over nature," Rosenblum said. "This is an unprecedented human drama."
"After he was killed, I picked up a picture of him that I had in the bedroom, broke the frame and started talking to him," Cohen said. "I told him: `You've been killed, all your dreams are gone, nothing is left of you.' Through his eyes he told me that it wasn't too late, and that there was still something to take from him.What bothers me about this case was the mother's statement, "...what is left for me to take?" I would have been more supportive if she had said, "what more could he give?" Organ donation should be pre-specified by the donor, not their loved one, and to violate this mandate crossed an important ethical boundary. As a physician, I would have a very hard time, indeed, granting the mother's wish to freeze her son's sperm unless he had requested organ donation before his death.
"I didn't understand. I said, `You're about to be buried; what is left for me to take?' Then I realized it was his sperm," Cohen said. "I used to be a nurse and I knew from the newspapers that sperm can be frozen. I rushed to the local army office and asked that his sperm be removed and frozen. It was done the same day."
- Wes
Sunday, January 28, 2007
The Supplication
“Dear God,
I bet it is very hard to love all of every body in the world. There are only 4 people in our family and I could never do it.”
– Nan
***
“Dear God,
Thank you for my baby brother but what I prayed for was a puppy.”
- Joyce
***
"Dear God,
Instead of letting people die and having to make new ones, why don't you just keep the ones you got now?"
- Jane
***
She was a 38 year-old mother of two kids with a warm personality and delightful smile. She had been plagued much her life with asthma but she had otherwise been fairly healthy. Her heart, she disclosed to her internist, had this nasty propensity to race when she became upset, exercised, or used her inhaler often. She complained about this to her doctor who ordered an exercise stress test and this is what it showed after 5 minutes of exercise:
For those not used to seeing an EKG, this one’s not normal. It demonstrates a rapid, wide-complex ventricular tachycardia (rapid heart rhythm arising in the lower chambers of the heart). The left bundle branch, inferior axis morphology suggested the ventricular tachycardia arose from the right ventricular outflow tract, just beneath the pulmonary valve. Although the cardiologist performing the exercise stress test usually gets a bit nervous when this rhythm starts during a treadmill test, the nice thing about this heart rhythm disturbance is it usually occurs in people with structurally normal hearts and is curable with catheter ablation (cauterizing the focus from where the arrhythmia arises). Alternative therapy with beta-blockers was not attempted because of the patient’s history of asthma.
So after carefully discussing the various therapy options with the patient, she chose catheter ablation.
“I’ll pray for you, Dr. Fisher.”
I didn’t know what to say initially, but thanked her and told her I’d see her on her surgical date.
***
Two weeks later, she arrived in our pre-op holding area with her hospital gown, IV, and surgical cap in place. Her friends and family surrounded her. She smiled contently as we prepped her for the procedure.
“Are you ready?”
“Yes I am.”
“Any last questions before we take you in the room?”
“No. You went over it pretty well during our visit.”
“Great, then we’ll get started…”
“Oh, Dr. Fisher?”
“Yes?”
“I had a dream last night. You see I prayed that your hands were guided to the exact spot of my fast heart beats. You’re going to do fine, you know.”
“Uh, sure, Ms. C. Thank you. I’ll see you in the room.”
I went to change into my scrubs and surgical attire. I entered the room and the staff were ready. I chose a simple approach using two catheters at first to make sure I could initiate the rhythm while she was sedated on our lab table. The catheters (wires) went in fine and I positioned one in the right ventricular apex and the other steerable ablation wire in the right atrium while we tried to start her rhythm in the lab.
At first we were not successful, but with the addition of a bit of Isuprel (an adrenaline-like medication we use to increase the heart rate), her tachycardia became easy to induce and was stable enough the permit careful mapping. I reached to the ablation catheter in the right atrium and placed it in the right ventricular outflow tract. The very first place I laid it appeared to be an excellent site for ablation. I couldn’t believe it. I asked my technician to pace from the ablation catheter tip. The paced EKG identically matched the spontaneous arrhythmia in all leads, even to the finest detail. The signal recorded from the ablation catheter tip preceded the surface electrocardiogram onset by 40 milliseconds (usually 30 milliseconds or so would suffice). Could it be? I dared not move the catheter.
I told my technician to prepare to perform the ablation. Once the energy settings and temperature adjustments were to my satisfaction, we applied radiofrequency energy to the tip of the ablation catheter. Her arrhythmia stopped three seconds after we started the lesion. Energy was continued for 47 seconds, then discontinued.
We tried and tried to re-initiate her heart rhythm disturbance and were no longer capable of re-starting the arrhythmia, even when she was given the Isuprel. We waited and kept trying to re-start the arrhythmia. Nothing happened. She was cured.
Total procedure time: 22 minutes.
Was it divine intervention? I have no idea. Frankly, it felt like pure blind luck. But to this day I have never had such a short, uncomplicated ablation procedure and I think back to her prediction and faith and I wonder...
-Wes
References: Kids Pray to God
I bet it is very hard to love all of every body in the world. There are only 4 people in our family and I could never do it.”
– Nan
“Dear God,
Thank you for my baby brother but what I prayed for was a puppy.”
- Joyce
"Dear God,
Instead of letting people die and having to make new ones, why don't you just keep the ones you got now?"
- Jane
She was a 38 year-old mother of two kids with a warm personality and delightful smile. She had been plagued much her life with asthma but she had otherwise been fairly healthy. Her heart, she disclosed to her internist, had this nasty propensity to race when she became upset, exercised, or used her inhaler often. She complained about this to her doctor who ordered an exercise stress test and this is what it showed after 5 minutes of exercise:
For those not used to seeing an EKG, this one’s not normal. It demonstrates a rapid, wide-complex ventricular tachycardia (rapid heart rhythm arising in the lower chambers of the heart). The left bundle branch, inferior axis morphology suggested the ventricular tachycardia arose from the right ventricular outflow tract, just beneath the pulmonary valve. Although the cardiologist performing the exercise stress test usually gets a bit nervous when this rhythm starts during a treadmill test, the nice thing about this heart rhythm disturbance is it usually occurs in people with structurally normal hearts and is curable with catheter ablation (cauterizing the focus from where the arrhythmia arises). Alternative therapy with beta-blockers was not attempted because of the patient’s history of asthma.
So after carefully discussing the various therapy options with the patient, she chose catheter ablation.
“I’ll pray for you, Dr. Fisher.”
I didn’t know what to say initially, but thanked her and told her I’d see her on her surgical date.
Two weeks later, she arrived in our pre-op holding area with her hospital gown, IV, and surgical cap in place. Her friends and family surrounded her. She smiled contently as we prepped her for the procedure.
“Are you ready?”
“Yes I am.”
“Any last questions before we take you in the room?”
“No. You went over it pretty well during our visit.”
“Great, then we’ll get started…”
“Oh, Dr. Fisher?”
“Yes?”
“I had a dream last night. You see I prayed that your hands were guided to the exact spot of my fast heart beats. You’re going to do fine, you know.”
“Uh, sure, Ms. C. Thank you. I’ll see you in the room.”
I went to change into my scrubs and surgical attire. I entered the room and the staff were ready. I chose a simple approach using two catheters at first to make sure I could initiate the rhythm while she was sedated on our lab table. The catheters (wires) went in fine and I positioned one in the right ventricular apex and the other steerable ablation wire in the right atrium while we tried to start her rhythm in the lab.
At first we were not successful, but with the addition of a bit of Isuprel (an adrenaline-like medication we use to increase the heart rate), her tachycardia became easy to induce and was stable enough the permit careful mapping. I reached to the ablation catheter in the right atrium and placed it in the right ventricular outflow tract. The very first place I laid it appeared to be an excellent site for ablation. I couldn’t believe it. I asked my technician to pace from the ablation catheter tip. The paced EKG identically matched the spontaneous arrhythmia in all leads, even to the finest detail. The signal recorded from the ablation catheter tip preceded the surface electrocardiogram onset by 40 milliseconds (usually 30 milliseconds or so would suffice). Could it be? I dared not move the catheter.
I told my technician to prepare to perform the ablation. Once the energy settings and temperature adjustments were to my satisfaction, we applied radiofrequency energy to the tip of the ablation catheter. Her arrhythmia stopped three seconds after we started the lesion. Energy was continued for 47 seconds, then discontinued.
We tried and tried to re-initiate her heart rhythm disturbance and were no longer capable of re-starting the arrhythmia, even when she was given the Isuprel. We waited and kept trying to re-start the arrhythmia. Nothing happened. She was cured.
Total procedure time: 22 minutes.
Was it divine intervention? I have no idea. Frankly, it felt like pure blind luck. But to this day I have never had such a short, uncomplicated ablation procedure and I think back to her prediction and faith and I wonder...
-Wes
References: Kids Pray to God
Saturday, January 27, 2007
Dragging My Heels in Healthcare
Intel’s Chairman Craig Barrett thinks I’ve been dragging my heels about using information technology in healthcare.
Hmmmm. Dragging my feet over something that represents hours of unpaid labor and exposure to litigation… What could I be thinking?
Yesterday in an interview by CNBC’s Maria Bartiromo at the World Economic Forum in Davos, Switzerland, Mr. Barrrett blamed the medical profession for lapses in implementing information technology in the healthcare arena in the area of chronic health management.
And Mr. Barrett, could there be an itsy bitsy reason that we have been dragging our feet? Could it be because no one is willing to compensate doctors for monitoring people using gizmos at home? Is this a trivial piece of information? I would suspect that you, “Mr. Swiss Alps,” don’t do much that isn’t going to compensate you, now do you? Or are you, “Mr. Six-Inches of Powder,” going to lead the charge at bridging this gap given your prescience on this issue?
It’s not about just getting the data to the doctor. That, sir, is NOT healthcare. Instead, it’s about differentiating signal from noise. With a data dump to doctor’s offices, who will sift through the mountains of data (pun intended) to determine which data represent a problem in a particular patient versus a significant change? Data can change in expected ways when certain drugs are administered: like the elevation of a white blood count after steroids are administered. Will your little data processor be capable of making higher-order decisions? Unlikely.
More importantly, if a data point exceeds a pre-defined parameter and a doctor like me is notified by an e-mail using your handy-dandy device, who will follow-up to make sure I received and acted upon the notification? E-mailing data this way, without personal contact, is like planting a sinister bomb on my desk that is waiting to explode in my face. If I don't happen to check my e-mail that week because I am inundated by the scores of aged entering their twilight years, will you take the liability heat, or will I?
Pompous, arrogant sound bites do little to address these critical issues regarding information technology’s application in health care.
I'm sure there's plenty of doctors who'd like to have a weekend in Switzerland to discuss our "economic" thoughts, too, Mr. Barrett. Just ask.
-Wes
Addendum: Dr. Helen has more discussion and interesting commentary on this post.
Hmmmm. Dragging my feet over something that represents hours of unpaid labor and exposure to litigation… What could I be thinking?
Yesterday in an interview by CNBC’s Maria Bartiromo at the World Economic Forum in Davos, Switzerland, Mr. Barrrett blamed the medical profession for lapses in implementing information technology in the healthcare arena in the area of chronic health management.
Bartiromo: Where else could technology enable better health care?Whoa there Mr. Barrett! Are you suggesting that manufacturing of home monitoring devices containing Intel chips is the responsibility of the health profession? Have WE been dragging our feet or have YOU?
Barrett: Well if you look at it from a standard engineering analysis, about 80% of the cost in health care is in people who are chronically ill or old, and the real issue there is in fact, to keep them out of the hospital. That’s remote diagnostics and remote monitoring. Taking care of people who are chronically ill in their home. How do you do that? Information technology. Remote monitoring devices fire that information back to the doctors’ office let them keep track of the individual without having the individual have to go to the doctor’s office. Diabetes, congestive heart failure, all these things are amenable to information technology (and) diagnostics in the home.
Bartiromo: You could have all your information on a chip, I guess.
Barrett: Of course you could. I mean, we could have done this a long time ago if the medical profession would kind of get with it in this space. They’ve been kind of dragging their heels.
And Mr. Barrett, could there be an itsy bitsy reason that we have been dragging our feet? Could it be because no one is willing to compensate doctors for monitoring people using gizmos at home? Is this a trivial piece of information? I would suspect that you, “Mr. Swiss Alps,” don’t do much that isn’t going to compensate you, now do you? Or are you, “Mr. Six-Inches of Powder,” going to lead the charge at bridging this gap given your prescience on this issue?
It’s not about just getting the data to the doctor. That, sir, is NOT healthcare. Instead, it’s about differentiating signal from noise. With a data dump to doctor’s offices, who will sift through the mountains of data (pun intended) to determine which data represent a problem in a particular patient versus a significant change? Data can change in expected ways when certain drugs are administered: like the elevation of a white blood count after steroids are administered. Will your little data processor be capable of making higher-order decisions? Unlikely.
More importantly, if a data point exceeds a pre-defined parameter and a doctor like me is notified by an e-mail using your handy-dandy device, who will follow-up to make sure I received and acted upon the notification? E-mailing data this way, without personal contact, is like planting a sinister bomb on my desk that is waiting to explode in my face. If I don't happen to check my e-mail that week because I am inundated by the scores of aged entering their twilight years, will you take the liability heat, or will I?
Pompous, arrogant sound bites do little to address these critical issues regarding information technology’s application in health care.
I'm sure there's plenty of doctors who'd like to have a weekend in Switzerland to discuss our "economic" thoughts, too, Mr. Barrett. Just ask.
-Wes
Addendum: Dr. Helen has more discussion and interesting commentary on this post.
Friday, January 26, 2007
Caffeine-Laced Donuts
This should be filed under "why didn't I think of this?"
With all the popularity of energy drinks, coffee stands, and Dunkin Donuts - these will sell like, er, hotcakes.
Hey, maybe I can add caffeine to hotcakes... or ice cream.... or ....
-Wes
With all the popularity of energy drinks, coffee stands, and Dunkin Donuts - these will sell like, er, hotcakes.
Hey, maybe I can add caffeine to hotcakes... or ice cream.... or ....
-Wes
Venture Philanthropists
In a sign of the ever-growing frustration with academic medical centers to produce translational research - that is, research that can move lab-based experiments from cell to bedside, large non-profits are beginning to turn to for-profit companies to leap the seemingly insurmountable FDA hurdle:
Academic medical centers desiring to participate in such trials need to appreciate the competitive disadvantage that they, too, are missing in the high-stakes world of clinical research. Maybe they, too, would then be privy to some of the "venture philanthropy" that exists in the marketplace.
-Wes
Reference: WSJ 26 Jan 2007, Section B1, "Why Non-Profits Fund For-profit Companies Doing Drug Research."
It's a sign of desperation. One reason there have been so few drug breakthroughs lately is that the profit motive actually works against the development of new pharmaceuticals. Drug companies suffer from blockbuster-itis, the belief that only billion-dollar almost-sure things need apply for development. As a result, even the most brilliant discovery may not be translated into a drug unless it has 10-figure sales potential. Also, short time horizons on the part of venture capitalists, who generally want to see their biotech bets pay off in three years, don't mesh well with the lengthy drug-development process.But the complicated business of moving a drug to market involves clinical trials as well. Perhaps nowhere else is the glacial pace of development slowed further than in academic medical centers, where highly-regulated Investigational Review Boards with over 20 members need to approve clinical trials before a research project can commence. While the well-meaning intent of such IRB's is for patient protection, more and more companies are moving away from academic centers in favor of busy clinical practices whose investigational oversight is less stringent, and approval process can takes weeks rather than months.
Academic medical centers desiring to participate in such trials need to appreciate the competitive disadvantage that they, too, are missing in the high-stakes world of clinical research. Maybe they, too, would then be privy to some of the "venture philanthropy" that exists in the marketplace.
-Wes
Reference: WSJ 26 Jan 2007, Section B1, "Why Non-Profits Fund For-profit Companies Doing Drug Research."
Wednesday, January 24, 2007
Pregnant Bellys as Ad Space
Now here's a new use for the pregnant belly:
-Wes
Jennifer Gordon wants to sell her body. Not the whole thing, just her pregnant stomach.Heh. You gotta love those Bears fans.
Gordon, a lifelong "die-hard Bears fan," already has airfare booked and a place to stay in Miami -- but no Super Bowl tickets.
She's hoping to remedy that by auctioning off ad space on her nearly nine-months-pregnant belly to the highest bidder -- or someone with really, really good seats. It's a last-ditch attempt by a season-ticket holder who lost out in the Bears lottery.
-Wes
Tuesday, January 23, 2007
Cholesterol Guidelines - Evidence Based?
The controversy over the appropriateness of using HMG CoA reductase inhibitors or "statin" drugs (e.g., atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin and simvastatin) to treat high blood cholesterol levels in hopes of to preventing the development of heart and vascular disease just heated up.
Drs J Abrahmson and JM Wright published an interesting article in The Lancet on their evaluation of guidelines for the treatment of hyperlipidemia:
With studies like this, there is no question that patients can become confused. Should I stop my statin drug? What drug is best?
The answer here is simple: ask your doctor. This article is not justification for discontinuation of statins, especially since it, too, is flawed by the retrospective nature of their data. Rather, the authors' point appears to expose an area that should be studied further to assure our ounce of prevention is not worse than a pound of the disease.
-Wes
Reference: J Abramson and JM Wright ,”Are lipid-lowering guidelines evidence-based?” Lancet, 20-26 Jan 2007, Vol 369, Issue 9557, pp 168-169.
Drs J Abrahmson and JM Wright published an interesting article in The Lancet on their evaluation of guidelines for the treatment of hyperlipidemia:
For adults aged between 30 and 80 years old who already have occlusive vascular disease, statins confer a total and cardiovascular mortality benefit and are not controversial.The authors argue that current guidelines are an extrapolation of secondary prevention trials, or data combined from secondary and primary prevention trials, and not based on randomized trials of just primary prevention in the hyperlipidemia literature. To establish a basis for their concerns, they performed a retrospective analysis of the data from primary prevention trials (which they admit were not perfect because some of the patients had known vascular disease) and discovered the following:
The controversy involves this question: which people without evident occlusive vascular disease (true primary prevention) should be offered statins? With about three-quarters of those taking statins in this category, the answer has huge economic and health implications. In formulating recommendations for primary prevention, why do authors of guidelines not rely on the data that already exist from the primary prevention trials?
We used two outcomes to estimate overall benefit (benefit minus harm): total mortality and total serious adverse events (SAEs). Total mortality was not reduced by statins (relative risk 0·95, 95% CI 0·89–1·01). In the two trials that reported total SAEs, such events were not reduced by statins (1·01, 0·97–1·05) (data on SAEs from the other trials were not reported). The frequency of cardiovascular events, a less encompassing outcome, was reduced by statins (relative risk 0·82, 0·77–0·87). However, the absolute risk reduction of 1·5% is small and means that 67 people have to be treated for 5 years to prevent one such event. Further analysis revealed that the benefit might be limited to high-risk men aged 30–69 years. Statins did not reduce total coronary heart disease events in 10,990 women in these primary prevention trials (relative risk 0·98, 0·85–1·12). Similarly, in 3239 men and women older than 69 years, statins did not reduce total cardiovascular events (relative risk 0·94, 0·77–1·15).There has already been interesting commentary on this subject, unfortunately it is by an individual who also wants to sell his book. Nonetheless, there is a large monetary incentive for the pharmaceutical industry to promote statins to the general population. One is left wondering if there could be a subgroup of asymptomatic individuals who really don’t need primary prevention treatment of hyperlipidemia, or if there are individuals in whom the risks of drug side effects exceeds the reward of primary prevention therapy.
With studies like this, there is no question that patients can become confused. Should I stop my statin drug? What drug is best?
The answer here is simple: ask your doctor. This article is not justification for discontinuation of statins, especially since it, too, is flawed by the retrospective nature of their data. Rather, the authors' point appears to expose an area that should be studied further to assure our ounce of prevention is not worse than a pound of the disease.
-Wes
Reference: J Abramson and JM Wright ,”Are lipid-lowering guidelines evidence-based?” Lancet, 20-26 Jan 2007, Vol 369, Issue 9557, pp 168-169.
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