Digitek Recalled

"Foxglove Season" (Digitalis purpurea)

Heard about this from a patient tip after she had a problem getting a refill at the local Walgreens as they scramble to re-stock:

Actavis has issued a nationwide recall of Digitek (digoxin tablets) due to the possibility that tablets with double-thickness, containing twice the approved level of active ingredient, may have been commercially released. The existence of double strength tablets poses a risk of digitalis toxicity in patients with renal failure. Digitalis toxicity can cause nausea, vomiting, dizziness, low blood pressure, cardiac instability, bradycardia, and possible fatality. Several reports of illness and injuries have been received.

Yikes! Check your meds, folks!

-Wes

The Wonders of Radiology Voice Recognition Software

It has become common practice for radiologists to migrate to voice-recognition software to expedite the processing of the myriad of reports that come their way and to save on transcription costs. Here is the actual final report received by one of our cardiologists and delightfully handed to me today:

"HISTORY: CHF.

COMPARISON: 04/20/2008.

Colon pulmonary vascular prominence is again identified, unchanged dirty mediastinal stool is enlarged, but stable. Atherosclerotic disease is present in the aortic arch. Bones are unremarkable.

IMPRESSION: Findings consistent with stable CHF.
XRAY CHEST SINGLE VIEW (Order #95511140) on 4/24/2008"

The radiologist was called and said, "What did I sign off on?"

We read back the report.

"Oh, my God!"

-Wes

Where Have All The Residents Gone?

Last night - a code - complete heart block. I was called it to place a temporary pacing wire in the ICU. Little time. Stress. Need to prepare the field. Gloves, does anyone have gloves? Could we prep the area? You have the central line kit? Could I get another set of hands?

Then I realized something. The residents who had so carefully run the initial code and get the patient to the ICU had vanished. Why? Don't they want to learn how to start a central line, or at least see one placed? Where are they?

After the dust settled, I came to realize what had happened.

So to them and the medical teachers everywhere, I dedicate my parody of Pete Seeger and Joe Hickerson's "Where Have All the Flowers Gone" popularized by Peter, Paul and Mary and Joan Baez:

Where Have All the Residents Gone?
Where have all the residents gone, long time passing?
Where have all the residents gone, long time ago?
Where have all the residents gone?
They’ve gone to the keyboards everyone.
When will they ever learn?
When will they ever learn?

Where have all the keyboards gone, long time passing?
Where have all the keyboards gone, long time ago?
Where have all the keyboards gone?
They’re now in the hospitals everyone.
When will they ever learn?
When will they ever learn?

Where have all the hospitals gone, long time passing?
Where have all the hospitals gone, long time ago?
Where have all the hospitals gone?
They’ve gone to the hospitalists, everyone.
When will they ever learn?
When will they ever learn?

Where have all the hospitalists gone, long time passing?
Where have all the hospitalists gone, long time ago?
Where have all the hospitalists gone?
Consulting the specialists, everyone.
When will they ever learn?
When will they ever learn?

Where have all the specialists gone, long time passing?
Where have all the specialists gone, long time ago.
Where have all the specialists gone?
They’re planning retirement, everyone.
When will they ever learn?
When will they ever learn?

Where have all the retirees gone, long time passing?
Where have all the retirees gone, long time ago?
Where have all the retirees gone?
They’re treated by residents, everyone.
When will they ever learn?
When will they ever learn?

-Wes

Grand Rounds Is Up!

Are you ready to ruum-ble? This week here at Doc Gurley is the Grand Rounds Smack Down edition, where the best contenders of the health care blogosphere wrestle down and dirty with tough, scary topics.

Go ahead, jump on in.

-Wes

1984

George Orwell's 1984 struck the Fisher household last night. We received this in the mail:



A government camera caught this traffic "infraction" and the ticket was set to me. But I, you see, was not the driver. My son was.

And so, a tangled conversation ensued, tempers flared, motives questioned, circumstances unknown and impossible to reconstruct - all caught in a series of still-frame photos. After all, there are laws - rules that must never be broken - absolutes - especially when you want to get paid, like the City of Chicago wants to get paid. I felt myself wondering if this is justice or a means to a very monetized end. Worse still, I was not the perpetrator, but the "responsible party."

In a strange way, I saw this ticket as an extreme example of "Pay for Performance (P4P)" - just like we are implementing in healthcare. P4P is another government-mandated endeavor to assure the best quality of healthcare through the use of "absolute truths" agreed upon by a body of experts. There can be no room for negotiation, no original thought involved. Follow the rules and you will get paid. After all, as the ticket says in the upper right corner, it's not about the patient, it's all about this:


Strange.

You see, there was some irony here for I had just run a red light, too.

The police had barricaded the railroad crossing gate near my home in front of the usual road I usually travel yesterday. I saw the railroad gate was malfunctioning: it kept going up and down, up and down repeatedly without pausing in any position. It seemed the stop light mechanism was tied to the gate's action, only turning green would never turn green before the gate lowered again. Without action, traffic would have never moved if each of us at that intersection had not used careful judgment and broken the stoplight law and proceeded with caution.

So I got home without incident, relieved that no one was hurt and that I had creatively problem-solved a predicament and done my part to relieve traffic congestion safely.

Now, though, I guess I'll wait for my ticket in the mail.

And look forward to inflexible Pay for Performance initiatives that make us march lock-step in the name of excellence in medicine.

-Wes

Stand Proud

Stand proud, young doctor, as you no longer get pizza for lunch from drug and industry reps. Medical students, residents, staff physicians and nurses the world over can look forward to the fact that no impropriety can ever be bestowed upon them since they will no longer be coerced by those clueless drug and industry reps. That's right, no more toys.

Clean.

Pristine.

Virginal.

So carry the flag of purity proudly.

Meanwhile, rest assured that others will be wined and dined to discuss the next purchasing contract, and some hospital administrators will continue to rub noses with their existing contract recipients in Las Vegas. Feel good knowing that once their contracts are re-approved, those same contractors will become a Premium Sponsor of the next Hospital Gala to the support the hospital's philanthropy fund...or, maybe a round of golf? After all, we mustn't forget that hospitals ARE the economy!

So hold your head high, dear employees, as you buy your own lunch. Take pride that your integrity can no longer be questioned, your mission pure, and the cause just...

...and revel in the knowledge that others are still making out like bandits.

-Wes

The New Bouncer

Click to enlarge image

-Wes

Reference.

The Surgeon General on CAM

Dr. Val has been doing a great job interviewing our 17th US Surgeon General, Vice Admiral Richard H. Carmona, M.D (see here, here and here). But today, in regards to a question on Complementary and Alternative Medicine (CAM), I wondered what he was saying... (see the comments).

When one considers that the pharameutical industry has spent more money on marketing recently than R&D, and that those advertising costs are passed down to our patients in the cost of their medications, might removing direct-to-consumer advertising be a better way to lower healthcare costs to our system?

-Wes

"I Wanna Be a DNR"

Pallimed has the parody based on Nickleback's "Rock Star."

Very, very clever.

-Wes

The Cause of the Pause

Reading Holters today, I can across this:

A 46 year-old man who drives trucks for a living submitted a Holter with a diary that was blank (no symptoms). Here's his starting rhythm - not too exciting:

Click to enlarge

A bit later, we see this:

Click to enlarge

Then we see this!

Click to enlarge

So you check the rate histogram of all of the beats for 24 hours and find this:

Click to enlarge

So what's the diagnosis? Does he need a pacemaker?

-Wes

Screening ADHD Kids with EKGs

Boy, it didn't take long for UVa Hospital to hop on the EKG bandwagon for kids with Attention Deficit, Hyperactivity Disorder (ADHD) after the AHA released their recommendations for EKG screening in kids on stimulant medications based on retrospective literature review and gut feelings.

Sheesh. I think Dr. Rob had the appropriate amount of skepticism here.

Although I know and respect many of the doctors who were tasked with making the best recommendation they could with little data on the subject, the AHA does a huge disservice to the doctor-specialists' credibility when they cozy up to the pharmaceutical companies with "roundtables" prior to such proclamations. One wonders if the Adderal folks helped with the recommendations before their exclusive patent expires in 2009, eh? Further, as the literature upon which the recommendations are based describe about a 2.3-3.5% false positive rate of EKG's in kids, this recommendation is going to cost more than one family a pretty penny.

-Wes

Publish or Perish

I woke this morning and realized that I had missed the Big Point in my last post.

Last night, I was lamenting over the fact that another EP journal had been born – one of a series of six new journals of the “Circulation” line from the American Heart Association – one more to try to scour to keep current.

But this morning I found myself asking, “Why more journals?"

In the era of the Internet, print media throughout the world is struggling. Readership of newspapers and magazines has plummeted as people migrate to the Internet, where information can be organized quickly specific to the reader’s desires. Print media can’t do that. I suspect medical journals are trying to adapt to this “specialization” of topics in a way as the Internet, but older titles have found themselves, like newspapers, with falling readership and fewer advertisers to support the printed word. But as free online peer-reviewed publishing devoid of commercial interests and vetted by the online-community in real-time takes hold, the threat to printed journals grows.

Moreover, every week, my office is inundated with scores of “free” journals filled with white papers promoting the next great widget or medical technique. There are even journals that summarize each week’s journals. These throw-away journals have become more sophisticated, too, with glossy print and all, as advertisers seek new ways to reach their prey: me, the doctor.

So the print media journal publishers, in their push to instill novelty while finely-tuning a more targeted readership, have created a new product line – something that advertising purchasers want. I mean, who’s going to drive the market for $2 million-dollar robots for catheter ablation other than cardiac electrophysiologists? It isn’t going to be the echo guys. Or how about promoting the next cool, high-tech 3-D echo machine, with latest sophisticated dyssynchrony-evaluating software package? Those echo guys are salivating.

Look at the titles of the new Circulation line of journals: Circulation: Arrhythmia and Electrophysiology, Circulation: Heart Failure, Circulation: Cardiovascular Genetics, Circulation: Cardiovascular Imaging, Circulation: Cardiovascular Quality and Outcomes, and Circulation: Cardiovascular Interventions. These titles no longer dwell on an the pathophysiology of an organ system in a patient any longer (remember "Heart?"). No, like the general internists who proceded the specialist with declining revenues, those broader journals had their day generating revenue and notariety. Now, the new titles reflect the era of specialization.

After all, that's where Medicare still pays and business opportunities lie...

...at least for now.

-Wes

New EP Journal Premiers

Seems the "Journal Wars" are heating up between the Heart Rhythm Society (which publishes HeartRhythm) and the American Heart Association:

Circulation: Arrhythmia and Electrophysiology is the first of the new "Circulation portfolio" of journals, designed to meet the growing demand for tightly focused information in areas at the cutting edge of cardiology. Circulation: Heart Failure will be the second journal to premier in coming weeks. The remaining four titles - Circulation: Cardiovascular Genetics; Circulation: Cardiovascular Imaging; Circulation: Cardiovascular Quality and Outcomes (Eds note: Can you say CMS and JCAHO??); and Circulation: Cardiovascular Interventions - are scheduled for launch later in 2008.

Each bimonthly issue of Circulation: Arrhythmia and Electrophysiology and the other new journals will be available in both print and online formats. The journal Web site, http://circep.ahajournals.org will also present "Publish Ahead of Print" articles and other online features.

William Stevenson, MD, director of the clinical cardiac electrophysiology program at Brigham and Women's Hospital and professor of medicine at Harvard Medical School, will serve as editor of the AHA's new EP journal.

I look forward to seeing the new issue, but damn, it seems there's just too many journals to keep up with these days!

Can you say "information overload?"

-Wes

Urologic Alignment

I mean, it's like lunar alignment, except for the male urologic system - all in the last 24 hours!

First, we find the penile theft story on Reuters (there was an administrator looking at me strangely today...), then I read about Happy Hospitalist's "boys" being counted (good luck, Happy), then Kevin pipes in on testicular protection devices, and shortly thereafter my wife shows me this video she was sent displaying a guy skydiving who needs one of Kevin's devices (seriously... er this is not a home movie).

Could someone tell me what's going on?

And to think that the "IU" deals with this stuff all the time...

-Wes

How the SubPrime Mortgage Mess Is Hitting Hospitals

Bloomberg:

"Patients at the largest hospital in southeastern Georgia are being treated without the latest magnetic resonance imaging and cardiac catheterization technology because of the auction-rate bond market collapse.

The Southeast Georgia Health System delayed spending $3.6 million to upgrade the medical equipment after interest on $94 million of its auction debt tripled to 11 percent in February, said Michael Scherneck, chief financial officer. Hospitals from California to New Hampshire face similar dilemmas because they used the dying auction market to raise at least $50.5 billion, according to data compiled by Bloomberg.

* * *

Auction-rate bonds allowed local governments, hospitals and universities to issue securities maturing in 20 years or longer at short-term rates. Investors fled the market in February on concern the creditworthiness of bond insurers that guaranteed the debt would deteriorate because of losses on securities tied to subprime mortgages.

Rates on some bonds soared to 20 percent after the dealers running the auctions stopped buying securities that failed to sell, triggering a penalty rate for issuers. More than 60 percent of the thousands of auctions conducted each week have failed since Feb. 13, data compiled by Bloomberg show.

And I thought gas prices were bad...

-Wes

Machiavellianism Run Amok

Imagine, such cavalier disregard! Where is the respect for such a caring corporation when workers behave in such a manner?

Whirlpool Corp.'s suspension of 39 production workers at an Indiana plant who were seen smoking after declaring themselves eligible for a $500 annual tobacco-free insurance discount may signal the end of the honor system that rules most corporate wellness programs, experts said Tuesday.

The action also underscores the difficulty of enforcing so-called voluntary programs when fines or incentives grow big enough to encourage cheating and snitching, they said.

How could simple workers look at their company's wellness program with such a jaundiced eye? Don't they realize that their company wants what's best for them? How could these workers so cynically take advantage of the corporation when everybody knows that only the corporation is supposed to take advantage of the workers. Could it be that the simple working man or woman is also capable of acting disingenuously?

Say it ain't so.

If this kind of thinking keeps going on, the "wellness" boys are going to have to fold up their binders and brochures and head back home.

-Wes

Addendum 26 Apr 2008 - A roundup on the issue is offered over at the New York Times.

Seidel's Subponea Quashed

Eric Turkowitz over at New York Personal Injury Blog has the good news on blogger Kathleen Seigel's (of Neurodiversity.com) subponea (headlined in my Grand Rounds 8 Apr 2008).

-Wes

Grand Rounds is Up at Dr. Val

Based on my favorite anatomic system:

That's right – I'm taking my inspiration from the limbic system, and have organized the posts according to the dominant emotion they elicit from readers. And because Dr. Val was one of those annoying medical students who brought 10 different colored highlighters to study class, I will also label some of the posts with the following tagging system (in brackets) to offer advanced readers an additional nuance:

[:-)] = A post that demonstrates literary excellence

[{] = Early bird – an author who got his/her submission in early, which is really convenient for the host(ess)

[:-/] = Naughty – an author who forgot to submit an entry to Grand Rounds but who was included nonetheless

Guess which one I was.

-Wes

Doctors vs. Administration

Aggravated DocSurg nails it once again.

Brilliant.

-Wes

EKG Du Jour - #4

Another case from the EKG Hall of Fame:

She was 79 and referred for evaluation of an "aortic valve disorder." She was told of a cardiac murmur 6 or 7 years ago, yet had been asymptomatic, without dizziness, shortness of breath, nor loss of conciousness. She did not feel skipped beats and had never had fevers. Her echo one month prior had demonstrated a very mildly stenosed aortic valve with a mean gradient of 12.2 mm Hg and an aortic valve area of 1.64 square centimeters with mild aortic insufficiency and normal left ventricular function. Her only medication at the time of evlauation was hydrochlorothiazide for hypertension.

As part of her workup, an EKG was ordered and is shown below:

Click to enlarge

What is demonstrated on the EKG and how should it be treated?

-Wes

Having fun? Don't miss these other EKG cases du jour: #1, #2, and #3.