Saturday, September 14, 2013
Wednesday, September 11, 2013
Today, an older lady has slipped at home and she's taped to a hard backboard with a rigid neck collar in place. It's routine for all patients involved in car accidents or falls or anything that could cause a spinal cord injury. When I see her, her head is bandaged with gauze stained with blood. While medical staff attach her to a cardiac monitor and blood pressure machine, the paramedic relays her medical history to anyone who will listen.
My head makes a subconscious examination of the patient and the room. It feels a bit like being in BBC series Sherlock, where small icons pop up on the screen detailing the detective's thoughts, observations, and deductions; white female, age 60ish (higher risk of intracranial bleeding, probably needing CT scan of head) moving fingers and toes (doubt spinal cord injury), talking to nurse (higher cognitive function intact), open eyes looking around the room (unlikely lens dislocation, oculomotor centre functioning normally). Within seconds, I know the chance of a devastating bleed in the brain or spinal cord injury is extremely low.
Training my mind to process the subtleties of the human body didn't happen after four years of medical school, but with years of repetition and thousands of patients. Some puzzles are more routine and easier to meld observations, questions and decisions into a diagnosis while others cases are confusing and unexpected – and much more demanding.
As I'm talking I realise that I spend a lot of time conversing with patients in unusual positions: upside down, talking to their backs, or during an invasive pelvic or rectal exam. But it's all very matter-of-fact – like an art appraiser or a farmer inspecting sheep. We're more hands on than other doctors – we often don't have the luxury of knowing the patents beforehand or have information of previous examinations.
I feel the right side of my patient's face and note the significant swelling. When I remove the bloody bandage to inspect it, blood spurts onto the floor, just missing my nurse. She's not too pleased. All the while I ask her questions about how she fell, where she lost consciousness, and whether she walked around afterwards.
Interestingly, there are studies into how long different medical specialities wait before interrupting their patients. On average it's between 18-23 seconds; for emergency doctors it can be less than ten. I don't want to be rude so I'll often let patients talk for a while before cutting them off – but the reality is I just want the facts.
An increasing number of visits to hospitals in the US each year overwhelms staff in most ERs on a weekly basis. Pair this with demands for improved documentation and an ever-present force pushing us to go faster and the patient-doctor dynamic changes. Instead of having a conversation with patients, I rapidly spew questions for terse answers in the least amount of time possible to get the vital information I need. Much as I love hearing stories, the information patients often want to share isn't always what I need.
But amid these short interactions, where I'm held to the standard of not missing a life-threatening condition, I also have two other important goals: show empathy and make a personal connection.
My patient tells me she tripped and fell and hit her head against a dresser before phoning a friend for help. But she let the dog out first. As we laugh over her priorities, I suture her squirting wound. Connecting with patients is necessary. Despite all advances in medical practice, every patient has a mortality of 100%. I can't prevent death. Delay it maybe, heal an acute injury, hopefully, but I can always alleviate suffering. And relating to patients as human beings, not just diagnoses, helps to do this.
Personal connections also help us empathise. We're privy to the pain, struggles, challenges, heartaches, joys and relief our patients' experience. But while emotional investment can be positive fuel, negative and disturbing stories drain internal emotional reserves; drug abuse, homelessness, mental health disorders, and the rapidly failing bodies of elderly patients comprise more than half of my patients. I relate to patients while in the room but as soon as I walk away I shed this bond.
It's a survival mechanism, nothing more: keeping their burden on my shoulders would weigh me down and interfere with my ability to care for future patients.
I see my own mortality in each patient encounter. Luckily, today it's good news and the accident could have been worse. Her head, neck, arm and leg aren't broken and her forehead will heal. It's nice to meet her and she thanks me for making her feel comfortable. But it's time to shed another relationship.
I've got 20 patients to care for at the same time. By the time I return to my desk, everyone wants my attention: nurses with medication dosing questions, technicians with ECGs to review, medical students waiting to present their patients … all while my phone is ringing – a clinic wants to transfer a patient to me.
A pace this rapid may drive some physicians to early retirement, yet for me the challenge is becoming a multitasking Jedi. It forces me to be mindful of the happenings of the entire 60-bed department. Sometimes I'm in total control, other days I realise I haven't eaten or used the bathroom for over eight hours.
Pressure in chaos keeps me on my game especially in such a humbling environment. Just when you think you have the patient relationship, the medicine, the patient flow down, something brings you back down to earth. A bad outcome or an inexplicable tongue-lashing from a patient alters your day and future practice for an unknown period of time.
But it makes me love my job even more. The diagnostic puzzles and ability to give care to people in times of need is a special combination that outside of my family gives my life a higher purpose. To practice medicine in an environment that expects 100% accuracy can be tough but it's my calling.
Brian Drummond is a practising doctor and a Clinical Assistant Professor at the University of Arizona's Health Sciences Centre. He is also Medical Director of the University of Arizona Medical Centre's South Campus.
He is also a former doctor for the Marines in California.
Tuesday, September 10, 2013
The Albert and Mary Lasker Foundation awards, often called the "American Nobels," will go this year to three scientists who helped deaf people to hear, two others who made fundamental discoveries about how the brain works, and two of the world's best-known philanthropists, Bill and Melinda Gates.
The prizes — $250,000 in each category — were announced Monday; the winners will be honored at a luncheon in Manhattan on Sept. 20. Since the foundation began making the awards, in 1942, 83 laureates have also won Nobel Prizes. These are the three categories and the winners:
CLINICAL MEDICAL RESEARCH Dr. Graeme M. Clark, 78, of the University of Melbourne in Australia; Dr. Ingeborg Hochmair, 60, of Med-El in Innsbruck, Austria; and Blake S. Wilson, 65, of Duke University in North Carolina.
The three scientists literally broke a sound barrier, developing the modern cochlear implant, a device that allows profoundly deaf individuals to hear and speak. They overcame enormous skepticism from other researchers and from advocates for the deaf, who said the earliest implants amounted to unethical human experimentation.
In 1978, the National Institutes of Health rejected an application for financing of human research on cochlear implants on "moral grounds." It later supported such efforts after limited early successes.
Dr. Hochmair and Dr. Clark, working independently, began their multichanneled cochlear implants in the late 1970s, an effort that Professor Wilson soon joined and went on to advance with a new strategy. The combined effort "for the first time, substantially restored a human sense with a medical intervention," the Lasker citation says.
Most hearing loss results from damage to the hair cells that help transmit sound waves through the snail-shaped cochlea in the inner ear to nerve cells the brain. The scientists' cochlear devices use electrical stimuli to bypass such cells; they directly stimulate the main auditory nerve that conveys messages to the brain for processing as hearing.
Cochlear devices have helped 320,000 recipients around the world; many are children who get the devices at age 1 or 2 and go on to attend regular schools. Most recipients can use cellphones and follow conversations in relatively quiet places.
Earlier devices offered limited benefit because many recipients could not understand spoken words without visual hints like lip reading. Dr. Hochmair and Dr. Clark improved on those devices, and in 1991 Professor Wilson reported a new speech-processing strategy that overcame the hurdle for most recipients. All the while, the scientists had to find techniques to minimize the risk of brain infections and other potentially fatal problems.
"In retrospect, we designers of implant systems had to get out of the way and allow the brain to do its work," Professor Wilson, an engineer who became a hearing scientist, said in an interview. "Once given a relatively clear and unfiltered input, the brain could do the rest."
BASIC MEDICAL RESEARCH Richard H. Scheller of Genentech in South San Francisco, Calif., and Thomas C. Südhof of Stanford University, for their study of neurotransmission, the process by which nerve cells communicate with other cells in the brain. When Dr. Scheller, 59, and Dr. Südhof, 57, set out independently 25 years ago to explore the field, much of it was virgin scientific territory. Researchers had not identified a single protein in the neurotransmission process.
The two scientists were cited for transforming what had been a rough outline into a number of molecular activities to provide insights into the elaborate mechanisms at the crux of neurological activities, from the simplest to the most sophisticated. They did so by systematically identifying, purifying and analyzing proteins that can rapidly release chemicals that underlie the brain's activities.
For example, the ability to taste, move limbs and use imagination depends on a biological relay system in which nerve cells spill chemicals to stimulate nearby neurons. The transmission process can take less than a thousandth of a second.
These two Lasker winners' discoveries are beginning to help provide a molecular framework for understanding normal functions like learning and memory as well as some of the most severe mental illnesses, including schizophrenia.
PUBLIC SERVICE Bill Gates, 57, and Melinda Gates, 49, were honored for "spurring initiatives and research that tackle some of the planet's toughest health problems." The couple have donated billions of dollars from their foundation and coordinated with a number of public and private agencies involved in health work, enhancing the quality of life of millions of people.
In an interview, Mr. Gates said he and his wife were "learning as we go" in raising the visibility of global health issues, collaborating with scientists to reduce the burden of diseases that largely affect the poor. That was an abiding concern of Mary Lasker (1900-94), who set up the foundation with her husband and lobbied for years to increase taxpayer investments in health research. Now, Ms. Gates said in the same interview, their successes are dividends from such research.
The Gates foundation's efforts include a heavy investment in buying vaccines for people in poor countries and in efforts to develop immunizations for diseases that have no vaccines yet. Another program seeks to educate African women waiting to give birth about simple nutritional measures to improve their family's health.
Still another is trying to develop low-cost toilets that do not require water, for use in Africa. Governments in poor countries do not have the money to conduct such research. Once the toilets are developed, wealthier countries can finance production on a larger scale. "Philanthropy can sometimes take the risk out of the equation" in undertaking the initial steps in the research, Ms. Gates said.
Despite the foundation's investments, "we're not even halfway through the kind of impact we can have in global health," Mr. Gates said, adding, "I wish we were."
At one time in his career, Mr. Gates was criticized as insufficiently generous in his philanthropy. But in an interview in 1998, when he announced a $100 million gift to speed the delivery of childhood vaccines to developing countries, he said:
"You can always look back and say, 'Hey, I could have sold all my Microsoft stock when I was 30 years old,' but that would have been worth a small fraction of what it is now, and that would have been all my philanthropy."
Monday, September 9, 2013
Ten days later, Ms. Izumi was rushed to an emergency room, where doctors discovered that her colon and rectum had been torn during the operation. She was hospitalized for five weeks, undergoing a series of procedures to repair the damage, including a temporary colostomy, according to her attorney Chris Otorowski.
But even though medical device manufacturers and hospitals are required to report every device-related death and serious injury to a database maintained by the Food and Drug Administration within 30 days of learning about an incident, no report about the case was made in 2009. Hospital officials declined to comment, and a spokeswoman for the manufacturer said it became aware of the incident only when Ms. Izumi filed a lawsuit. It disputed the claim and settled the case in May 2012.
That was not the only lapse in reporting problems with robotic surgical equipment, a new study has found.
The equipment, called the da Vinci system, is made by Intuitive Surgical Inc. of Sunnyvale, Calif. It has been on the market for more than a decade; more than a million procedures have been performed with it. Between January 2000 and August 2012, thousands of mishaps were reported to the F.D.A. In the vast majority of cases, the patient was not harmed, but among the reports were 174 injuries and 71 deaths related to da Vinci surgery, according to a study published last week in The Journal for Healthcare Quality.
Yet by combing news reports and court records, researchers at Johns Hopkins were able to find examples of botched operations that were not reported to the agency. They concluded that adverse events associated with the da Vinci were "vastly underreported."
It is fairly well known that reports made to the F.D.A. represent only "the tip of the iceberg" of surgical complications and adverse drug reactions, said Diana Zuckerman, the president of the National Research Center for Women and Families and an expert on the safety of medical devices, who was not involved in the study. The consequence is that little is known of the real disadvantages of the equipment, and the injuries and deaths it may cause, even as robotic surgery is widely marketed to consumers, Dr. Zuckerman said.
In a statement, Angela Wonson, vice president of corporate communications at Intuitive, said that the new study "gives the misleading impression that Intuitive Surgical has systematically failed in its obligation to timely report known adverse events to the F.D.A." On the contrary, she said, "We take this requirement very seriously and make every effort to account for all reportable events — even those from several years prior."
The new study follows a series of reports critical of robotically assisted surgery. Documents surfacing in the course of legal action against Intuitive have outlined the aggressive tactics used to market the equipment and raised questions about the quality of training provided to surgeons, as well as the pressure on doctors and hospitals to use it — even in cases where it is not the physician's first choice and she has little hands-on experience.
Nevertheless, robotic surgery has grown dramatically, increasing more than 400 percent in the United States between 2007 and 2011. About 1,400 da Vinci systems, which cost $1.5 million to $2.5 million, have been purchased by hospitals, according to Intuitive's investor reports.
The expansion has occurred without proper evaluation and monitoring of the benefits, said Dr. Martin A. Makary, an associate professor of surgery at Johns Hopkins and the senior author of the paper.
"This whole issue is symbolic of a larger problem in American health care, which is the lack of proper evaluation of what we do," Dr. Makary said. "We adopt expensive new technologies, but we don't even know what we're getting for our money — if it's of good value or harmful."
Part of the problem is that the reporting mandate "has no teeth," Dr. Makary added. "In health care, one fifth of the economy, we have this haphazard smattering of reports that relies on voluntary self-reporting with no oversight, no enforcement and no consequences."
F.D.A. officials said in a statement that the agency has issued warning letters in the past when facilities have failed to report, and that the agency can take further regulatory actions like injunctions or imposing civil financial penalties.
A 2010 study found that 56.8 percent of surgeons surveyed anonymously said they had experienced irrecoverable operative malfunctionswhile using the da Vinci system, Dr. Makary noted.
Women were more likely to be harmed during the robotic procedures, Dr. Makary and his colleagues found. Nearly one-third of deaths that were reported to the F.D.A. database occurred during gynecologic procedures, and 43 percent of the injuries were associated with hysterectomies.
"Any time there is a serious problem with the da Vinci, it should be reported," Dr. Zuckerman said. "It's the F.D.A.'s job to figure out whether this is a problem related to the device or a doctor error."
The woman with the swollen red leg was selling us one bill of goods after another. She said she had stopped injecting drugs years before; the fresh needle marks on her feet suggested otherwise. She said she had duly taken all the antibiotic pills another hospital had given her, although most people don't finish those prescriptions.
But we didn't raise an eyebrow at the least likely claim of all. Instead we wrote it down carefully in our notes and it became a part of her hospital record, highlighted in red on the computer and set off with an exclamation point, permanently molding her medical life and also, in a way, our own.
This was her life-threatening allergy to penicillin.
About one in 10 Americans reports a serious allergy to the antibiotic penicillin or any of several closely related drugs. Yet in about 90 percent of cases, no serious allergy exists.
Some people are using the word allergy imprecisely. Antibiotics can have all kinds of dreadful side effects, from diarrhea to nerve damage, but most of these are not formally considered allergies.
Some people confuse antibiotics: an older woman once described to me in spine-chilling detail the swollen lips and wheezing that had kept her away from penicillin since before World War II. But penicillin wasn't around then, and she probably had a sulfa allergy instead.
A few people — or, more likely, their doctors — mix up the disease and the treatment. Syphilis and Lyme disease can sometimes dramatically worsen in the hours following effective treatment, but that isn't a drug allergy either.
Some people may have only a mild allergy. Ampicillin in particular can cause a rash that is annoying but not dangerous.
Meanwhile, people with the throat-swelling, heart-stopping immediate reaction to penicillin called anaphylaxis often outgrow it. Fewer than half will remain allergic after five years.
In other words, the chances were good that we could have treated that angry infected leg with a penicillin drug without running into problems. It was by far our best and cheapest option.
But we routinely sidestep this particular gamble. The odds may be strongly in our favor, more than for most of the risks we routinely take, but it is hard to say who is more terrified by the prospect of overriding a patient's allergy history, the patient or the hospital's lawyers.
So a couple of times a week, we briefly consider our options, right and wrong.
The right option is not to proceed like a bunch of cowboys, gleefully administering the penicillin ourselves. The right option is to address the matter with the available scientific tools. A system of skin tests can predict with precision whether a person can safely get penicillin and its many relatives.
At this point in our discussion, if it gets this far, we always look at each other with some confusion. Are the chemicals needed for a skin test available these days? (The major one was off the market for quite a few years but now is back again). Who does the testing, anyway? (It needs an experienced hand. Is that person still working here?)
Somebody should definitely find out the answers, for sure, we say. But at the moment we are in a big hurry. We need to get this woman on treatment so she can get better and vacate that expensive hospital bed for somebody else.
Our patient is not one of the rare individuals who absolutely needs penicillin. Plenty of other antibiotics will help her. These days, only certain patients with syphilis have no good treatment alternatives. For them we deploy not only skin tests (which take about an hour in the right hands) but even the painstaking daylong desensitization procedures that can briefly defuse the immune reaction to the drug.
For every other patient, we head cheerfully down the wrong path. It takes us less than seven seconds to choose among various other antibiotics. They are more expensive than a penicillin drug would be, and also more powerful. They will kill off a lot of innocent intestinal organisms that our patient would probably be better off keeping. They will let drug-resistant variants thrive and escape into the world.
But our patient's leg will get better, and that is our visible focus. The resistant microbial population in her gut, our hospital, our other patients, our community and our very own selves (no man is an island when it comes to microbes) are invisible.
She is only one patient in one hospital, but the sum total of all those decisions in all the patients like her in all the hospitals in the country is chilling. Or rather, it would be chilling, if we had the time to sit down and think about it.
The future of health is open
The stories we share here are inspired by health innovation from around the globe. We bring to life how technology, transparency, information-sharing, and community-building are playing a vital role in the ways people are thinking about health.
We are beginning to see greater transparency in healthcare, as a result of efforts to improve general health around the world. Examples of this include:
- Greater clarity in medical costs
- Better and more prominent nutritional information at restaurants and on food packaging
- Including the patient as a partner in his/her own care
- Improving information-sharing among physicians and medical records systems
Health is becoming social
The connectivity we all enjoy today allows for quick and easy sharing of health information. We are building communities and social networks that are focused on health and medicine. Many people—for example, those with chronic conditions that might have previously curtailed their social interaction—are able to go online to find others who share their health concerns. They—and everyone else—can reach out to peers for health information and advice. And despite the occasional episode of internet-based hypochondria (You probably don't really have a brain tumor. Or a guinea worm.), better informed patients can make better decisions.
These now-forming networks also allow doctors and individuals to connect and share knowledge much more quickly. And smart mobile health apps can further advance the way we communicate with health providers.
You can join the open health conversation.
Have you seen transparency, collaboration, and community efforts to improve health where you live? Have you heard about it happening elsewhere? Let us know.
Not sure where to start? Check out the list of topic ideas below, and see if something strikes your fancy.
- Transparency in patient health records data
- Who owns the patient data in electronic health records—the software provider, the doctor, or the patient?
- Does meaningful use mean more collaboration in care?
- Ways to collaborate with and better involve patients as active participants in their own care
- Health record exchange - Compelling doctors to collaborate and share records with each other
- The pharmaceutical industry - collaborative clinical trials, drug patents and exclusivity, the generic-versus-name-brand dilemma
- OpenNotes project
- Blue Button project
- Aneesh Chopra's visit to the Healthcare Information and Management Systems Society (HIMSS) and opening data
- New bill advocating transparency in medical insurance rate changes
- Greater cost transparency, i.e., doctor visits, procedures, even simple tests so we can make more informed medical decisions.
- One procedure can cost one sum in one place and a vastly different sum somewhere else.
- mHealth and eHealth provide easier access and help shrink the health disparity gap
- Social health (building health networks in social media)
- Open data in healthcare
Miracle babies, wounded soldiers, and hurricane victims: Grim and uplifting articles about hospitals. - Slate Magazine
The Longform guide to hospitals.