Friday, December 16, 2011

As Doctors Use More Devices, Potential for Distraction Grows -

Hospitals and doctors' offices, hoping to curb medical error, have invested heavily to put computers, smartphones and other devices into the hands of medical staff for instant access to patient data, drug information and case studies.

But like many cures, this solution has come with an unintended side effect: doctors and nurses can be focused on the screen and not the patient, even during moments of critical care. And they are not always doing work; examples include a neurosurgeon making personal calls during an operation, a nurse checking airfares during surgery and a poll showing that half of technicians running bypass machines had admitted texting during a procedure.

This phenomenon has set off an intensifying discussion at hospitals and medical schools about a problem perhaps best described as "distracted doctoring." In response, some hospitals have begun limiting the use of devices in critical settings, while schools have started reminding medical students to focus on patients instead of gadgets, even as the students are being given more devices.

"You walk around the hospital, and what you see is not funny," said Dr. Peter J. Papadakos, an anesthesiologist and director of critical care at the University of Rochester Medical Center in upstate New York, who added that he had seen nurses, doctors and other staff members glued to their phones, computers and iPads.

"You justify carrying devices around the hospital to do medical records," he said. "But you can surf the Internet or do Facebook, and sometimes, for whatever reason, Facebook is more tempting."

"My gut feeling is lives are in danger," said Dr. Papadakos, who recently published an article on "electronic distraction" in Anesthesiology News, a journal. "We're not educating people about the problem, and it's getting worse."

Research on the subject is beginning to emerge. A peer-reviewed survey of 439 medical technicians published this year in Perfusion, a journal about cardio-pulmonary bypass surgery, found that 55 percent of technicians who monitor bypass machines acknowledged to researchers that they had talked on cellphones during heart surgery. Half said they had texted while in surgery.

About 40 percent said they believed talking on the phone during surgery to be "always an unsafe practice." About half said the same about texting. The study's authors concluded, "Such distractions have the potential to be disastrous."

Doctors and medical professionals have always faced interruptions from beepers and phones, and multitasking is simply a fact of life for many medical jobs. What has changed, doctors say, especially younger ones, is that they face increasing pressure to interact with their devices.

The pressure stems from a mantra of modern medicine that patient care must be "data driven," and informed by the latest, instantly accessible information. Annual investment in gadgets and other technology by hospitals and doctors has soared into the billions of dollars.

By many accounts, the technology has helped reduce medical error by, for example, providing instant access to patient data or prescription details.

Dr. Peter W. Carmel, president of the American Medical Association, a physicians group, said technology "offers great potential in health care," but he added that doctors' first priority should be with the patient.

Indeed, doctors and nurses face growing pressures to listen carefully to patients, provide customer service and show empathy as they look for subtle cues that might explain an illness.

"The computer has become a good place to get a result, communicate with other people," said Abraham Verghese, a doctor and professor at the Stanford University Medical Center and a best-selling medical writer. "In the interest of preventing medical error, it's a good friend."

At the same time, he said, the wealth of data on the screen — what he frequently refers to as the "iPatient" — gets all the attention.

"The iPatient is getting wonderful care across America," Dr. Verghese said. "The real patient wonders, 'Where is everybody?' "

It is hard to know the precise impact that distracted doctoring has on patient care, because it is hard to measure. But at least one example puts the risks in sharp relief.

Scott J. Eldredge, a medical malpractice lawyer in Denver, recently represented a patient who was left partly paralyzed after surgery. The neurosurgeon was distracted during the operation, using a wireless headset to talk on his cellphone, Mr. Eldredge said.

"He was making personal calls," Mr. Eldredge said, at least 10 of them to family and business associates, according to phone records. His client's case was settled before a lawsuit was filed so there are no court records, like the name of the patient, doctor or hospital involved. Mr. Eldredge, citing the agreement, declined to provide further details.

Others describe multitasking as relatively commonplace.

"I've seen texting among people I'm supervising in the O.R.," said Dr. Stephen Luczycki, an anesthesiologist and medical director in one of the surgical intensive care units at Yale-New Haven Hospital. He said he had also seen young anesthesiologists using the operating room computer during surgery.

"It is not, unfortunately, uncommon to see them doing any number of things with that computer beyond patient care," Dr. Luczycki said, including checking e-mail and studying or entering logs on a separate case. He said that when he was in training, he was admonished to not even study a textbook in surgery, so he could focus on the rhythm and subtleties of the procedures.

When he uses computers in the intensive care unit, he regularly sees what his colleagues were doing before him.

"Amazon, Gmail, I've seen all sorts of shopping, I've seen eBay," he said. "You name it, I've seen it."

Dr. Luczycki is also a huge fan of technology's positive impact on medicine. So, too, is Dio Sumagaysay, administrative director of 24 operating rooms at Oregon Health and Science University hospitals, even though he has heard about or witnessed instances of people using devices during critical moments.

In early 2010, he heard several complaints that doctors or nurses were using their phones to check or send e-mails even though they were part of a team intubating a patient before surgery.

Mr. Sumagaysay established a policy to make operating rooms "quiet zones," banning any activity that was not focused on patient care. He later had to reprimand a nurse he saw checking airline prices using an operating room computer during a spinal operation.

Medical professionals say young doctors can be particularly susceptible to distraction because they have grown up being constantly connected.

At Stanford Medical School, for example, all students now get iPads, which they use to read medical texts and carry with them in hospitals but are also admonished not let get in the way of their work.

"Devices have a great capacity to reduce risk," Dr. Charles G. Prober, senior associate dean for medical education at the school, said. "But the last thing we want to see, and what is happening in some cases now, is the computer coming between the patient and his doctor."

Thursday, December 15, 2011

Emergency contraceptives over the counter: Are they more dangerous than other drugs? - Slate Magazine

Health and Human Services Secretary Kathleen Sebelius overruled the FDA's recommendationthat emergency contraception be made available over the counter to patients of all ages on Wednesday. Her argument was that its effects on 11-year-olds have not been thoroughly studied. Critics pointed out that many over-the-counter drugs are far more dangerous than emergency contraceptives. What's the most dangerous drug you can buy without a prescription?
It's hard to say. As far as the Explainer can tell, no researcher has ever compared the fatality rates of every drug available over the counter—probably because the number of deaths from overdose of antacids and many other products is so small as to make the study a waste of time. There is, however, a large body of research on pain relievers. Analgesic overdoses are pretty common in the United States. In 2000, poison-control centers received more than 130,000 calls from people who believed they had taken a dangerous amount of an over-the-counter painkiller. Nearly one-half of those calls concerned acetaminophen, best known as the active ingredient in Tylenol. Approximately 0.2 percent of those cases ended in death. That's higher than the reported death rate for nonsteroidal anti-inflammatory drugs like Advil (ibuprofen) and Aleve (naproxen), but lower than the fatality rate for aspirin. (Aspirin is technically in the same category, but is often separated for research purposes.)* However, most of the aspirin deaths appear to have been suicides, while accidental overdose is more common than intentional overdose for acetaminophen. Between the years 1990 and 1998, 458 people died from taking too much acetaminophen.*
Pseudoephedrine, a very common cold medication, is also implicated in a number of deaths every year. In 2004, for example, poison-control centers reported 21 deaths in which the chemical was involved. However, most of those patients took a cocktail of drugs—often including acetaminophen—and many of the cases were ruled suicides. It's also not entirely correct to call pseudoephedrine an over-counter drug. A 2005 act of Congress forced retailers to move it behind the counter because of its use in the production of methamphetamine.
Of course, many other drugs can be fatal if you go way overboard. Even Epsom salts, which are commonly used as a laxative, can cause cardiac arrest. A hospital in Scotland reported a case of attempted suicide by Epsom salts in 2009. The woman ingested an incredible 4.4 pounds of the stuff. She suffered some acute cardiac complications, but doctors were able to save her.

It's not easy to determine the fatal dose of over-the-counter drugs. Take the example of acetaminophen. A person's ability to handle the drug depends on a variety of factors, including the condition of their liver, how much they've eaten, and whether they take the pill in conjunction with alcohol. (Bad idea.) Compared to other over-the-counter drugs, acetaminophen has a relatively narrow safety margin—that is, the difference between a safe-but-effective dose and an overdose is relatively small. Doctors have reported liver failure from as little as 2.5 grams in a day, which is 1.5 grams less than the approved limit.

The FDA has considered reducing the approved daily dose (PDF) of over-the-counter acetaminophen, but that wouldn't help in all cases. Many patients don't realize how much of the drug they're taking. Those who are prescribed the painkiller Percocet, for example, might take over-the-counter acetaminophen as an adjunct for different or breakthrough pain. The problem is that Percoset contains acetaminophen, and the combination can easily put them over the dose limit.
What's the fatal dose of emergency contraceptive? Nobody knows. The drug certainly has side effects, like nausea, vomiting, dizziness, fatigue, and the like. Women who use the morning-after pill as their regular form of contraception can also experience some menstrual irregularities. But no one has taken a fatal dose of Plan B.

Wednesday, December 14, 2011

Painkillers for N.F.L. Players? Not So Fast -

The former professional football player is confused. It is difficult for him to pinpoint, after the pads have come off for good, the precise cause of his aching body and his aching soul. He knows that the game did it. But what part of the game? Was it the physical violence? The psychological warfare? The realization that his life peaked in his 20s? The drugs he took to stay on the field? Whatever the cause, there is always the pain. The pain is constant in football and as a result it is constantly being manipulated.

Last week a group of 12 former National Football League players filed a class-action lawsuit against the league, claiming that the N.F.L. and its teams failed to warn players of the side effects of the drug Toradol, widely administered to players before games to numb pain. The lawsuit contends that the use of the drug masked injuries like concussions and thus further endangered the athletes.

When I played for the Denver Broncos, from 2003 to 2008, Toradol was a popular pregame injection. The night before we took the field, 10 to 20 of us would go into a designated room and stand in line to receive our shots. I don't remember what, if any, specific injury I was nursing on any particular occasion. I do remember that my body was perpetually feeling bad, as were those of my teammates. Our training staff knew this and would encourage us to get a shot. We were told it would make us feel better. So we lined up for the needle.

When I got to the front of the line, I was told that the shot was known to cause internal bleeding in a very small percentage of patients but otherwise was safe. This disclaimer was given with needle in hand and a line of men waiting behind me. There was no hesitation, no trepidation, no point at which I felt that taking Toradol was a risk. I trusted our team doctors. They wouldn't suggest a drug if it was dangerous.

The big risk, in my mind, was not being at my best the next day. The big risk was not taking the shot, playing poorly and being viewed by the staff as unwilling to do what it took to help the team win. The big risk was losing my job.

The N.F.L. is a machine. The operators of the machine pull its levers more frantically every season, pushing it past its breaking point. So the league has stockpiled interchangeable spare parts. The broken ones are seamlessly replaced and the machine keeps rolling. The old pieces are discarded and left to rust in a scrap heap.

This harsh reality is softened by human relationships. Football players spend every day with the members of their team's medical staff. They learn to trust them. The athletic trainers nurse the players back to health when they are injured. The team doctors perform their operations. Friendships are formed and bonds are created. But underneath it all hums the machine.

Athletic trainers are paid to keep the machine humming. The long-term health of the individual player is not their first concern; the health of the team is. The faster a trainer gets his players back on the field, the more likely he'll be to keep his job. Trainers are under pressure to do this by masking a player's pain with drugs and designing a hasty rehabilitation schedule, even if it inevitably trades one injury for the next.

The player rarely if ever has a say in the treatment process. When he is injured, the athletic trainers and team doctors take the necessary X-rays and M.R.I.'s and decide on the course of action among themselves. Only afterward do they tell the player what injury they have found and how they will treat it. If the player seeks a second opinion, which he is technically allowed to do, it is taken as an affront to the medical staff, and he will be treated in the training room like a turncoat. The medical staff issues its reports to the head coach, and is often beholden to him, which is another reason that players don't challenge their diagnoses or treatments.

The player is not told how to access his medical records or whether he even has a right to them. The folder of my medical records was as thick as a dictionary and I never had access to it. Even after I filed a workers' compensation lawsuit against the Broncos a year ago that later included a request for that folder, I still don't have it. The team hasn't released it to me.

If the N.F.L. is serious about protecting its players, it should appoint a league-wide medical body, unaffiliated with any specific team, to oversee players' health. Such an institution would be able to provide care to the athlete without the interests of his team distorting treatment.

Until then, teams will continue to convince players that their bodies and brains are ready for professional football, even when they are not. The injured body needs coaxing. It needs to be stroked, rubbed, heated, stretched and lied to. There are coaches, owners, trainers, fans and a host of media people counting on the players, after all, ready to question their manhood if they decide that the pain is too much to bear.

But the next game, the game that right now feels so important, will pass. In a couple of weeks, few will ever speak of it again. And then it's on to the next one. And the machine will keep humming.

Nate Jackson is working on a book about life in the N.F.L.

Facebook launches tool to report suicidal behavior | Reuters

Facebook launched a new suicide prevention tool on Tuesday, giving users a direct link to an online chat with counselors who can help, the company said.

Friends are able to report suicidal behavior by clicking a report option next to any piece of content on the site and choosing suicidal content under the harmful behavior option, Facebook spokesman Frederic Wolens said.

Facebook will then email the user in distress a direct link for a private online chat with a crisis representative from the National Suicide Prevention Lifeline as well as the group's phone number.

The new tool gives people who may not be comfortable picking up the phone a direct avenue to seek help.

"This was a natural progression from something we've been working on for a long time," Wolens said.

Users also have the ability to report suicidal behavior by going to the site's Help Center or search for suicide reporting forms. They can also use reporting links around the site.

Worried friends who reported the behavior will also receive a message to say it is being addressed, Wolens said.

Facebook, the most popular Web-based social networking site, has more than 800 million active users worldwide. The Palo Alto, California-based company was co-founded by Mark Zuckerberg in 2004.

The new suicide reporting tool will be made available to people who use Facebook in the United States and Canada.

Wolens said that all reporting on the site is done anonymously and so a distressed user will not know who reported the suicidal content.

Nearly 100 Americans die by suicide every day, according to the Surgeon General of the United States.

In the past year, more than 8 million Americans 18 or older had thought seriously about suicide, according to a blog post by the Surgeon General accompanying the release of the new Facebook tool.

Monday, December 12, 2011

Many elderly screened for cancer despite doubts | Reuters

Although the benefits of cancer screening in elderly people are often less certain than the risks, many silver-haired Americans are still getting the routine tests, researchers said Monday.

More than half of women ages 75 to 79 in a nationwide survey said they were being screened for breast cancer and had had recent Pap smears to look for signs of cervical cancer.

Similarly, most men in that age group had been screened for prostate cancer recently. The numbers dropped some for people over 80, but were still high.

That's despite the fact that there is still substantial uncertainty over the potential benefits of screening tests in the elderly.

"Historically older adults have been excluded from screening trials, so the screening efficacy data in this population are really limited," said Keith M. Bellizzi, a public health researcher at the University of Connecticut, who lead the new work.

While some screening tests -- say, mammography or colonoscopy -- have been shown to save lives in middle-aged adults, all have downsides.

There is the cost of looking for disease in people who feel fine, for instance, and the potential complications of procedures such as colonoscopies. The tests may also sound a false alarm that can lead to unnecessary biopsies, and in some cases doctors diagnose and treat cancers that would never have caused any harm if left alone -- a phenomenon known as overdiagnosis.

The benefits may outweigh the risks in younger adults, but as people get older and sicker, the balance tips.

"At a minimum, in order to see any benefit of screening, you would want your patient to have a life expectancy of more than five years," Bellizzi told Reuters Health.

And screening people who have other health problems may also require extra thought, he added.

"If you are going to screen in older adults for a cancer, you wouldn't want to do that unless you're sure that individual would be able to tolerate that treatment," Bellizzi said.

He and his colleagues used data on more than 4,000 Americans 75 and older, who had been interviewed in 2005 and 2008 as part of the National Health Interview Survey. Their findings appear in the Archives of Internal Medicine.

The researchers found that 57 percent of seniors aged 75 to 79 had been screened for colon cancer, and 56 percent of men had been screened for prostate cancer in the past year.

Sixty-two percent of similarly aged women had been screened for breast cancer within the past two years, and 53 percent had been screened for cervical cancer sometime during the past three years.

Medical groups differ somewhat in their screening advice, especially for older adults in whom the benefits are less certain.

The government-backed U.S. Preventive Services Task Force, for instance, either recommends against routine screening of people 75 and older, or says the evidence is insufficient to balance the benefits and harms, depending on the type of cancer.

The American Cancer Society, on the other hand, has no upper age limit for its colon cancer recommendations, but notes that men whose life expectancy is less than 10 years should not be offered prostate cancer screening.

Bellizzi warned that his data didn't show why people were being screened, and so couldn't tell whether or not the tests were being used appropriately.

While some screened seniors may be healthy and have a long life ahead of them, others may be very unlikely to get anything but harm from screening.

How to separate those two groups is a question that hasn't received attention, he said.

"Over 50 percent of physicians are continuing to recommend screening tests in older men and women," Bellizzi said. "I'm hopeful that these findings will serve as a catalyst for an important dialogue that needs to take place."

For graying citizens who face the choice of whether or not to get screened, he said they should weigh their options with their physicians based on their personal values and preferences.

"I would recommend for patients to have a real thoughtful conversation with their provider to talk about the potential harms and benefits of screening," Bellizzi said.