Archive for July, 2010

OK, Couch Potatoes! Study on Health and Mortality Questions – How Long Can We Afford to Sit Each Day?

Thursday, July 29th, 2010

Have you ever added up the total amount of time that you sit everyday?  In the car, on the bus, on the train, in the office, on the couch..the list goes on and on.  Now, new information, published by The American Journal of Epidemiology, brings to the surface some enlightening and scary statistics of what happens when we “sit for too long.”

This information has saturated the internet over this past weekend.  One of many places where this information is summarized is on the MedlinePlus website.  Within the article, the statistics regarding the risks to women versus men are clearly defined:

The authors of the study analyzed responses from questionnaires filled out by 123,216 people (53,440 men and 69,776 women) with no history of disease who were participating in the Cancer Prevention II study conducted by the American Cancer Society.

Participants were followed for 14 years, from 1993 to 2006.

In the study, people were more likely to die of heart disease than cancer. After adjusting for a number of risk factors, including body mass index (BMI) and smoking, women who spent six hours a day sitting had a 37 percent increased risk of dying versus those who spent less than three hours a day on their bottoms. For men the increased risk was 17 percent.

Exercise, even a little per day, did tend to lower the mortality risk tied to sitting, the team noted. However, sitting’s influence on death risk remained significant even when activity was factored in.

On the other hand, people who sat a lot and did not exercise or stay active had an even higher mortality risk: 94 percent for women and 48 percent for men.

Exercise is important.  OK – we knew that, but what about the report that sitting’s influence on death risk remained significant even when activity was factored in? How is that problem addressed and solved?

The answer to that question is not clear.  What is clear is the relationship between a lack of activity and obesity, as well as other factors.  These biological factors are known as “inactivity physiology”.  Study lead author Dr. Alpa Patel, an epidemiologist with the American Cancer Society, states the following:

There’s a burgeoning literature evolving around “inactivity physiology.”  When muscles, especially those in the legs, are “sitting,” they stimulate or suppress various hormones which then affect triglycerides, cholesterol and other markers for heart and other diseases.

This newly-released information is sure to spark debate and concern for some time to come.  The question remains “How long can we afford to sit each day?”  I don’t know the answer, but I think I will stand up now and walk around awhile…

New First-Of-Its-Kind Study: 70,000 Children Injured Annually by Medical Devices

Thursday, July 29th, 2010

A new first-time study of injuries suffered by children as a result of medical devices has produced some startling statistics. “More than 70,000 children and teens go to the emergency room each year for injuries and complications from medical devices,” according to an article in The Washington Post, which highlights a study just published by the American Academy of Pediatrics.

Although the study points out that only 6% of all of these injuries required hospitalization, the fact remains that there is still a very large number of children that suffer injuries due to medical devices.  Some injuries are due to malfunction and misuse, while others are from very dangerous events, such as “puncture wounds from hypodermic needles breaking off in the skin while injecting medicine or illegal drugs”. According to the The Washington Post article:

The most serious problems involved implanted devices such as brain shunts for kids with hydrocephalus (water on the brain); chest catheters for cancer patients receiving chemotherapy at home; and insulin pumps for diabetics. Infections and overdoses are among problems associated with these devices.

In addition, the article touches on a recent trend that has come with medical advances: home health care, for such treatments and procedures which previously required longer and more extensive hospital stays:

Dr. Steven Krug, head of emergency medicine at Chicago’s Children’s Memorial Hospital, said the study highlights a trade-off linked with medical advances that have enabled chronically ill children to be treated at home and live more normal lives.

Home care can be challenging for families; Krug says he has seen children brought in because catheters were damaged or became infected.

“Health care providers need to be aware of these kids and their devices and how to recognize or diagnose” related problems, Krug said.

All of this being said, the article suggests that the Food and Drug Administration may soon become more involved, due to the nature and extent of these injuries to children:

The researchers are working to determine how and why the injuries occurred and also are examining the prevalence in adults. Those efforts might result in FDA device warnings, depending on what they find, said study co-author, Dr. Brock Hefflin.

Hefflin and lead author Dr. Cunlin Wang work in the FDA’s Center for Devices and Radiological Health. They note there has been recent concern about medical device safety in children, particularly since many devices intended for adults are used in children.

We leave you with this conclusion, as stated by the American Academy of Pediatrics:

This study provides national estimates of pediatric medical device-associated adverse events resulting in emergency department visits and highlights the need to develop interventions to prevent pediatric device-related injuries.

Is this an adequate response?  What do you think?

New Guidelines for Vaginal Births After Cesarean Section – Abandoning the Principle of “Once a Cesarean Always a Cesarean”

Thursday, July 29th, 2010

For decades, expecting mothers were encouraged to deliver via C-section if they had a history of previous C-sections. The maxim “once a cesarean, always a cesarean” became the default approach for many OB/GYNs around the country. This may no longer be the case.

This year, the American College of Obstetricians and Gynecologists issued a number of less restrictive guidelines for vaginal births after C-sections. According to William A. Grobman, M.D. an associate professor of obstetrics and gynecology at Northwestern University and co-author of the new guidelines, women with two previous C-sections and no vaginal deliveries, women expecting twins, and women with vaginal scarring from previous C-sections are now acceptable candidates for vaginal deliveries. The new guidelines are supported by two recent studies that examined the risk of complications in women with a history of two previous C-sections who attempted vaginal delivery.

One [study] found no increased risk of uterine rupture in women with one vs. multiple previous C-sections, while the other study found the risk increased from 0.9% to 1.8% in women with one vs. two previous C-sections.

The new guidelines make the following recommendations:

  • Women with more than one previous C-section may be candidates for a trial of labor. … The chance of achieving a vaginal birth after C-section seems similar for women with one or more than one C-sections.
  • Women who have an unknown type of scar from a previous C-section can also be considered for a trial of labor.
  • Women expecting twins can be offered the trial of labor.
  • A trial of labor is not recommended in others, including women who are at high risk for complications, such as women with a previous uterine rupture or extensive uterine surgery.
  • Previous guidelines recommended that resources for emergency C-sections be ”immediately available.” “That was interpreted to mean all staff, literally immediately available,” Grobman says. In the new guidelines, the ACOG recommends that a trial of labor after C-section ideally be done in facilities well staffed to provide immediate emergency care, but that in a facility without immediate staff available, those doctors and patients discuss the resources and staff availability and carefully consider the decision to try labor.

The new guidelines clearly encourage vaginal deliveries for expecting mothers with previous C-sections. However, Grobman and his colleagues were clear that, although the risk appears minimal, trial of labor after C-sections does carry a number of risks, including uterine rupture, hemorrhage, and infection. For this reason, notwithstanding these  new recommendations, the expecting mother and the physician should carefully discuss and consider the decision to try labor. If you meet the criteria, we urge you to fully understand the potential risks, complications as well as the benefits of vaginal birth after Cesarean Section.

Stevens-Johnson Syndrome: one mother’s plea to ‘get the word out’ and one son’s story of horror.

Sunday, July 25th, 2010

Last week I wrote a blog based on a report in USAToday about how many doctors and parents – primarily the latter – are likely to avoid giving their children pain medication when it’s prescribed and needed.

Within minutes of posting this piece, I received a reply on Twitter from a woman who seemed to take exception to the blog or at least wanted me to be aware of the potential dangers of using pain medication in children. Specifically, she wanted me to be aware of what had befallen her son after he had taken Motrin – he was stricken with a horrible condition known as Stevens-Johnson Syndrome.

After communicating back and forth with her that day and going to her blog about her son’s coming home from the hospital following his treatment, I asked her if I could use her son’s story as the nucleus for a blog on Stevens-Johnson Syndrome and how medication can be a cause for this potentially fatal problem. She told me this would be fine since she wanted to get the word out about Stevens-Johnson Syndrome and the role medications can have in its development.

What is Stevens-Johnson Syndrome?

Rather than paraphrase the experts on what this syndrome is, here’s how the Mayo Clinic defines it online.

Stevens-Johnson syndrome is a rare, serious disorder in which your skin and mucous membranes react severely to a medication or infection. Often, Stevens-Johnson syndrome begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters, eventually causing the top layer of your skin to die and shed.

Stevens-Johnson syndrome is an emergency medical condition that usually requires hospitalization. Treatment focuses on eliminating the underlying cause, controlling symptoms and minimizing complications.

The authors then note that it can take “weeks to months” to recover from Stevens-Johnson Syndrome. If it’s determined that it was caused by a medication, then “you’ll need to permanently avoid the medication and all others related to it.”

What are the risk factors?

While Stevens-Johnson Syndrome (SJS) is a rare and unpredictable condition, certain factors can increase a person’s risk to suffering this complication: viral infections (such as the common cold), HIV and systemic lupus erythematosus (SLE) – relative compromises of the body’s immune system. It is also reported that if you carry a gene known as HLA-B12, you may be more susceptible to SJS. Some claim that people of Asian ancestry are at increased risk if taking certain medications (Carbamazepine (Tegretol); screening for such special susceptibility is available, according to some reports.

How sick are people who suffer from SJS?

They typically require hospitalization in an intensive care unit. As mentioned, the treatment can take weeks to months.

How is it treated?

There is no known treatment other than supportive care in the form of fluid replacement, skin care and medications to treat the symptoms (e.g. antihistamines for itching, steroids for inflammation of your skin, pain medication and the like) and to prevent the progression of SJS by giving immunoglobulin intravenous (IGIV) therapy to improve and bolster the patient’s immune system.

What areas of the body are affected by SJS?

According to an article published on emedicine.medscape.com:

SJS typically involves the skin and the mucous membranes. While minor presentations may occur, significant involvement of oral, nasal, eye, vaginal, urethral, GI, and lower respiratory tract mucous membranes may develop in the course of the illness. GI and respiratory involvement may progress to necrosis. SJS is a serious systemic disorder with the potential for severe morbidity and even death (my emphasis).

What is Toxic Epidermal Necrolysis (TEN) and what is the difference between SJS and TEN?

SJS is often discussed in the same literature that relates to the another condition known as Toxic Epidermal Necrolysis (TEN). While there is some disagreement among those in medicine, a number of experts consider SJS and TEN to be expressions of erythema multiforme.  Often the conditions are commonly referred to as SJS/TEN. One definitional classification differentiates the two conditions in this manner:

  • Stevens-Johnson syndrome – A “minor form of TEN,” with less than 10% body surface area (BSA) detachment
  • Overlapping Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) – Detachment of 10-30% BSA
  • Toxic epidermal necrolysis – Detachment of more than 30% BSA

What are the causes of SJS/TEN?

While opinions vary, the causes are often listed as (1) infectious, (2) drug-induced, (3) malignancy-related, and (4) idiopathic (unknown). Some report that more than half the patients with SJS/TEN have had a recent upper respiratory tract infection.

What medications can cause SJS/TEN?

SJS and TEN are often associated with taking certain forms of medications: NSAIDS (non-steroid anti-inflammatory drugs -), Allopurinol, Phenytoin (Dilantin), Carbamazepine, barbiturates, anticonvulsants, and sulfa antibiotics (common examples - Septra®, Bactrim® and Pediazole®).

What race, sex and age groups are most affected?

Caucasian males between ages 20 and 50. (Source: emedicine.medscape). Needless to say, this group is simply identified as the most statistically likely to suffer from SJS/TEN. For example, the ratio is 2:1 for men; children as young as old as three (3) months of age have been diagnosed with this dreaded condition. Some claim that African-Americans and Asians are at increased genetic risk for SJS/TEN. One wonders – are these statistics really helpful in making a diagnosis?

What are the signs and symptoms of SJS/TEN?

Once again, relying on the experts at the Mayo Clinic, here is a list of some of the signs and symptoms:

  • Facial swelling
  • Tongue swelling
  • Hives
  • Skin pain
  • A red or purple skin rash that spreads within hours to days
  • Blisters on your skin and mucous membranes, especially in your mouth, nose and eyes
  • Shedding (sloughing) of your skin

If you have Stevens-Johnson syndrome, several days before the rash develops, you may experience:

  • Fever
  • Sore throat
  • Cough
  • Burning eyes

How many people affected by SJS/TEN die?

Mortality is determined primarily by the extent of skin sloughing. When BSA sloughing is less than 10%, the mortality rate is approximately 1-5%. However, when more than 30% BSA sloughing is present, the mortality rate is between 25% and 35%, and may be as high as 50%. Bacteremia/sepsis may also contribute to mortality. (See source)

What is the lesson, if any, learned?

Needless to say, this posting is not in any way intended to be a full-blown medical research article on SJS/TEN. Having heard this mother’s story of her son’s fight to overcome the ravaging effects of SJS, his continuing problems with scarring and her concern that such might befall some other parent’s child, I decided to simply “get the word out” on this little known but horrible syndrome.

Where does the answer lie on this issue of medications? How does one assess the risks versus the benefits of taking medication? I don’t purport to have the answers to these questions. Be aware of the risk; be aware if you are in a risk group; be aware of the signs and symptoms.

Seek immediate medical care if you believe you are having an adverse reaction to a medication.

While there is no magic pill or cure, immeidiate supportive medical management and care in a proper facility are essential to minimizing the ravaging effects of the syndrome. As noted by many medical authors, since SJS/TEN is such a relatively rare disorder, it is many times not diagnosed in a timely fashion. If you suspect that what you are seeing is SJS or TEN – even as a lay person – raise the issue with your treating physician. Remember – early, effective intervention is your best chance to arrest the progress of this horrible condition.

Many thanks to my new friend on Twitter, who brought this issue to my attention and let me use her son’s story to “get the word out.” Speedy and complete recovery to you, Andrew!

$8 Million Verdict in Fosamax trial – Jawbone Destroyed By Drug

Thursday, July 22nd, 2010

A landmark verdict against the pharmaceutical giant Merck was recently rendered in a Fort Walton Beach Florida courtroom.  It should raise wide-spead public concern over the safety of drugs called bisphosphonates prescribed for mostly women as treatment for osteoporosis and osteopenia.  Bisphosphonates  are a drug classification that includes Fosamax, Fosamax + D, Aredia, Boniva, Didronil, Actonel, Actonel + Ca, Reclast, Skelid,  and Zometa.

Limited news reports tell the story of Shirley Boles, a 72 year old great grandmother and retired sheriff’s deputy, who was taking the drug Fosamax for osteopenia.  The condition of osteopenia is a normal thinning of the bones as a person ages.  It does not typically result in bone fractures unless it progresses to the disease osteoporosis. Current medical practices recommend treatment to prevent the development of osteoporosis.

Ms.  Boles also had a history of periodontal disease and smoking. She began experiencing jaw problems after taking Fosamax over a 10 year period of time.  She ultimately needed extraction of two teeth. Following the extraction, a very serious  condition called osteonecrosis of her jaw was diagnosed. In essence, the bone in her jaw disintegrated and died.  Jurors witnessed the physical decaying bone matter and infection seen from two drains in her chin. They heard how Ms.  Bales only eats soft food and will need to undergo repeated surgeries to replace her dead jawbone.

How the condition osteopenia went from a research term to an actual disease classification for some people and not others, and how Merck advanced their money-losing drug Fosamax to treat the new disease is a fascinating read.

NPR broke the story during Christmas 2009.  That same month, it was also reported that 10 million people in the United States had osteoporosis and most were women.  That same year,  45 million bisphosphonate prescriptions were written in the US generating $4.9 billion. Given the holiday season, one must wonder how many people actually became aware of this story.

The tale actually begins with the publication of an article released by the Wall Street Journal in December 8, 2004.  The story noted that in 2001, the Chief of Oral Surgery at the Long Island Jewish Medical Center, Dr. Salvatore Ruggiero, began recognizing a distinct pattern of osteonecrosis and jawbone death in 8 cancer patients taking the drug Aredia to combat bone loss.  He reported his cases to the FDA. He continued to track 90 of his subsequent patients, who developed jawbone osteonecrosis while taking Aredia and Zometa.  During this period, other oral surgeons were also reporting the same findings, including the Chief of Oral and Maxillofacial Surgery at the University of Miami’s Miller School of Medicine, Dr. Robert Marx.

The drug company Novartis, which makes Aredia and Zometa, first reported the side effect of osteonecrosis of the jaw (ONJ) on drug inserts in 2003.  By 2004, Novartis had received 500 reported cases in cancer patients taking Aredia and Zometa.  In September 2004, the FDA issued their first warning associated with intravenous bisphosphonates. In June 2006, the National Osteoporosis Foundation put out a Scientific Statement that ONJ associated with bisphosphonate therapy was seen 95% of the time in cancer patients and only rarely in the general osteoporosis patient population.

Ms. Boles did not have cancer.

The American Society of Oral and Maxillofacial Surgeons (ASOMS) put out a clinical position paper in September 2006. Their clinical research found increased risk factors for ONJ in those receiving both intravenous AND oral bisphosphonates.  There was a definite risk increase in patients taking the drugs for more then 3 years, but ASOMS concluded more study was needed. In addition, ASOMS noted a seven-fold increase in patients who had a history of periodontal disease and oral abscess. Diabetes, smoking, and alcohol also increased risk.

Current drug inserts and patient information do not list (ONJ) in drug contraindications or warnings.  However, under general precautions the inserts say ONJ can “occur spontaneously in association with tooth extractions, dental implants, and bony surgery.  It can also occur in cancer patients receiving cancer treatments.  Persons at risk include those with poor oral hygiene, periodontal disease, pre-existing dental disease, anemia, coagulopathy, and ill-fitting dentures.”

In 2009, an article was published in the Journal of the American Dental Association involving the University of Southern California dental clinics.  The results were even more alarming.  The researchers found out of 208 patients taking the drug Alendronate, also known as Fosamax and sold by Merck, nine had active ONJ.  This represented 1 in 23 patients, 4% of the general dental clinic population.  The researchers concluded the incidence may be much higher then previously reported, and the risk appears great even in short term users.  The study author noted there was a 10 year half-life of the drug remaining in bone tissue.  So dentists and patients need to be alerted to the risk remaining over a period of time.

Faulty drug design was the basis for Mrs. Boles $8 million dollar verdict.  Merck plans to appeal.  In the meantime, how many woman taking bisphosphonates remain uninformed of this potential risk?

Study Warns of Many Parents “Undertreating” their Kids for Pain

Tuesday, July 20th, 2010

USATODAY has recently posted an article on-line, regarding how prevalent the undertreatment of children is when it comes to follow-up medical care after an injury or surgery.

As more and more hospitals send children home fairly quickly after surgery – many within hours after an outpatient procedure – it falls on parents to monitor and control their child’s pain.  This can be frightening for some parents, confusing to others, or a combination of both.  As a result, many parents just flat-out refuse to give pain medication to their kids.  What percentage of parents don’t give adequate pain relief through medication to their children?

In a study of 261 children, 24% of parents gave either no medication or a single dose, even though 86% of parents reported that their child was in “significant pain” on the first day after surgery, according to the study of children ages 2 to 12 published in October in Pediatrics. Doctors typically advise parents to give pain relievers every four hours as needed.

What makes the issue of pain involving children even more challenging is that it is not always easy to tell whether a child is in pain or to what extent.  What are some of the signals that a child is in pain? Here’s some insight:

Recognizing and treating pain in children can be a challenge. Unlike adults, kids may not cry or complain when in pain, says Lisa Humphrey, Medical Director of the Pediatric Palliative Care Program at Rainbow Babies & Children’s Hospital in Cleveland. Instead, kids may show these symptoms:

• Refusing to eat or drink.
• Becoming quiet, withdrawn.
• Having trouble sleeping.
• Becoming fussy.
• Showing other changes in mood or behavior.

It is also suggested that doctors do more than just write a post-procedure prescription and then hand it to the child’s caregiver. Pediatrician Zeev Kain, Chairman of Anesthesiology at the University of California-Irvine, encourages doctors to take an active role in advising and guiding parents in the aftercare of their little ones:

“[D]octors give parents relatively little information about how to care for these young patients,” Kain says. “It’s not enough to hand parents a prescription,” he says. “Doctors and nurses need to make sure parents will actually give the medication.”

“Without such guidance, parents who are afraid of medication side effects often intentionally withhold medication,” he says.

Once a caregiver is educated and knows what to do and how to do it, then there is the issue of having the child actually take the medicine. What if they are fussy, don’t like the taste, or simply will not listen?  Dr. Humphrey provides one answer:

Parents also can request that children try a dose of medication before leaving the hospital, to make sure they are willing to swallow it.

Dr. Mark Brown, an ear, nose and throat specialist in Austin, provides another:

If children don’t like the taste, parents can ask pharmacists to create alcohol-free versions, which are more palatable, says Mark Brown, an ear, nose and throat surgeon in Austin. Many pharmacies are now willing to add a child’s favorite flavor, such as orange or grape.

So, the next time the doctor hands you that prescription for your little one, and your mind starts to race with questions about dependency, side effects, or issues involving how to administer the medication, there is one thing you can do before the doctor turns to leave to see the next patient: ask for help and guidance!

Newborn Mortality Rate Significantly Higher in Home Births – Are Home Births Worth the Risk?

Friday, July 16th, 2010

A recent study published by the American Journal of Obstetrics & Gynecology suggests that there is a significant increase in the newborn mortality rate in cases of planned home births when compared to hospital deliveries. The study conducted by Joseph R. Wax. M.D. included data from 342,056 planned home births and 207,511 planned hospital deliveries. The data was collected from a number of industrialized Western nations. Researchers found that:

Although rare, newborn deaths occurred in 0.2% of the total planned home births included in the analysis, compared with 0.09% of the total planned hospital births. Among infants born without any birth defects, the rates were 0.15% vs. 0.04%, respectively.

These findings suggest that, in cases of home birth, the newborn mortality rate was almost twice as high when compared to hospital deliveries and almost tripled in cases involving newborns with congenital abnormalities. One explanation for these findings is that newborns have less medical intervention, which can result in respiratory distress and failed resuscitation.

This data is particularly surprising considering that most women, who participated in home births, had fewer overall obstetrical risk factors (e.g., obesity, previous pregnancy/delivery complications, c- sections). Additionally, the study also suggests that while the newborn mortality rate increased in cases of home births, the mothers were less likely to develop a number of complications, including infections, perineal/vaginal lacerations, bleeding, and retained placentas.

For many women, the decision to proceed with a home birth vs. a hospital delivery is not an easy one. It is usually motivated by a number of factors, such as preconceived notions about medical care, family history, and opinions regarding c-sections, among many other things. If you are expecting, whatever you do, make an educated decision about your delivery.

Many doctors don’t blow whistle on colleagues

Friday, July 16th, 2010

Picture this scenario:  You are a doctor, and one of your very closest friends is also a physician.  You know for a fact that he/she has a terrible substance abuse problem and/or it has become readily apparent to you that they are incompetent within the practice of medicine.  You see it day in and day out.  There have been a few “close calls” where your friend’s impairment could have caused catastrophic results to one or more of their patients.  Your friend conceals their problems well.  What would you do?

A new study recently published by the American Medical Association (AMA) addresses this and other similar scenarios.  How frequently this occurs and why more physicians don’t report their colleagues’ problems were highlighted in a recent article in the USA Today, that reviewed the AMA’s study:

A surprising 17% of the doctors surveyed had direct, personal knowledge of an impaired or incompetent physician in their workplaces, said the study’s lead author, Catherine DesRoches of Harvard Medical School.

One-third of those doctors had not reported the matter to authorities such as hospital officials or state medical boards. The findings, appearing in Wednesday’s Journal of theAmerican Medical Association, are based on a 2009 survey of 1,891 practicing U.S. doctors.

There are several reasons for not reporting colleagues to the proper agencies.  Most notably, the fear that their colleagues would lose their medical license and livelihood.  However, as the article details, doctors have an ethical obligation to report other practitioners’ substance abuse problems and lack of competency issues:

The American Medical Association and other professional groups say doctors have an ethical obligation to make such reports. And many states require doctors to tell authorities about colleagues who endanger patients because of alcoholism, drug abuse or mental illness.

“I don’t think there’s any excuse for less than 100% of physicians holding true to these ideals,” said Dr. Matthew Wynia, director of the AMA Institute for Ethics.

Despite these ethical protocols, the concern and problems with non-reporting continue. So again we ask, what would you do in this situation, and what do you want to see done to correct this apparent problem within the medical profession?

So just what is ‘Defensive Medicine’? The other side of the ‘story’ being told.

Wednesday, July 14th, 2010

There is a recurring theme being pushed on the public that trial lawyers are driving up the cost of healthcare by making doctors so afraid of lawsuits that they are practicing “defensive medicine” in order to protect themselves.  A recent survey reported in the Wall Street Journal indicates that approximately 90% of doctors surveyed believe that doctors order more tests than needed in order to protect themselves from lawsuits, with an estimated $60 billion being spent each year on such unnecessary treatment.  This report must be taken with a grain of salt at best.

First off, what exactly is defensive medicine?  Is it performing medical procedures that are unnecessary? Is it tests to check for diseases that are statistically unlikely?  Is it tests whose results turn out to be negative (and, therefore, deemed not needed in the first place)?  There is no clear-cut definition of what constitutes defensive medicine.  A quick review of the term on Google shows a number of definitions that all boil down to some variation of the following – ordering tests or procedures out of concern to reduce exposure to malpractice suits rather than out of concern for quality patient care, or refusing to treat high-risk patients or undertake high-risk procedures with the same goal in mind.  In other words, it is the doctor’s motivation in ordering a test – and not the appropriateness of the test itself – that apparently defines defensive medicine for the purposes of these studies.

Even if you can define defensive medicine, how is it measured?  By asking subjective questions of the doctors themselves as to how often they believe they practice defensive medicine.  Are doctors keeping track of each order they write over the course of a year?  Are they keeping track of each test or procedure they perform with a notation of the specific motivation that drove them to get each test?  Of course not! This survey does nothing more than capture a doctor’s subjective (and clearly undocumented) “feeling” as to how often defensive medicine is practiced.  And then a dollar figure is thrown in at the end of the study that is supposed to represent the cost of defensive medicine.  However, without a clear definition, and without a clear test for measuring what tests and procedures are being performed unnecessarily, it is impossible to assess a monetary value for defensive medicine or test the validity of the “estimated $60,000,000,000. (Also, given that doctors are the subject of lawsuits, might one reasonably assume that the doctors have a bias in answering these questions?).

Inherent in this theory of the high costs of defensive medicine is that trial lawyers are constantly bringing frivolous lawsuits that are resulting in million dollar settlements or jury verdicts.  This is simply not the case.  I don’t know any reputable malpractice lawyer who sets out to file frivolous lawsuits.  Those who do should be sanctioned.  At our law firm, we decline the vast majority of inquiries we get from injured patients, which is in line with the experience of other law firms that specialize in medical negligence.  Many of these cases are rejected only after careful review by expert physicians in the field, who tell us that they believe the care was appropriate.  Furthermore, the law in Maryland requires that before a lawsuit can even be filed against a doctor or hospital, the plaintiff must obtain a certificate under oath from an expert in the same field of medicine who, after reviewing the records, has determined that the defendant doctor violated the standard of care and caused injury to the patient.  Frivolous lawsuits cannot even make it past the system’s initial screening stage.

This theory of defensive medicine also leads us to a more fundamental question – what level of care does the law expect of doctors? It is a common misperception that plaintiff’s lawyers expect doctors to perform every available test on every patient, no matter what, or else they’re going to get sued.  Some doctors go to great lengths to perpetuate this myth.  For example, in a recent article on the topic of greedy trial lawyers, a doctor was quoted as saying (and I’m paraphrasing) that if someone comes into an Emergency Department nowadays with a headache, that person is going to get an MRI, a CT scan, you name it.  With all due respect to this doctor, he is wildly exaggerating to make a point.

To answer the question of what is expected for doctors, the law has developed a standard to which health care providers must comply, and that standard is “reasonableness.”  A doctor breaches the standard of care when he or she fails to do what a reasonable physician would have done in the same or similar circumstances.  No more and no less.  The law does not demand perfect care or extraordinary care, and the law does not punish doctors simply because there has been a bad outcome. (There is actually a jury instruction in the District of Columbia called the “Bad Result” instruction that tells jurors they cannot find the doctor liable just because there simply was a bad outcome).  The law only requires that a doctor act reasonably in the circumstances.

As a simple example, let’s say that a patient (a 50-year-old man) sees his primary care physician because he developed low back pain after a weekend spent lugging around bags of mulch in his back yard.  His back is painful and stiff. In that context, what level of care do we expect of the doctor?  If we are to believe the theory of defensive medicine, this primary care doctor would immediately refer the patient to get an MRI, a CT scan, and a consultation with a neurosurgeon just to be sure that he doesn’t get sued.  For anyone who’s ever had back pain and gone to the doctor, he or she can realize how silly this scenario is.

Let’s take another example.  A 38-year-old man comes into the Emergency Department with chest pain.  Questioning by the doctor reveals that he has no history of heart problems or other serious illness.  It is also learned that he just wolfed down a large pizza and a few beers after his company softball game.  The doctor thinks it’s probably just a case of indigestion or heartburn, but to be safe he orders an electrocardiogram to check for heart problems.  This test comes back normal.  Is this defensive medicine?  Does this ER doctor consider it defensive medicine for the purposes of answering survey questions?  Should the EKG not have been done because the odds of a heart attack were minimal?  In this situation, one can easily make the argument that the EKG was reasonable.  Even though the risk of a heart attack was small, the severity of harm to the patient if the diagnosis is missed is great.  Shouldn’t we encourage reasonable testing that catches life-threatening illness?

There is obviously a balance between over-reacting and under-reacting, which is where the concept of reasonableness comes into play.  We applaud doctors exercising medical judgment as they were trained to do, and we expect them to act reasonably.  However, when doctors fail to act reasonably and injure a patient, the law provides a mechanism by which the patient can recover. At the end of the day, it isn’t trial lawyers who determine what is reasonable or unreasonable treatment.  It is juries that decide, after listening to both sides of the story.

The Hidden Dangers of Button Batteries

Wednesday, July 14th, 2010

Sunday evening, immediately after putting our two year old to bed, my wife and I watched 60 Minutes and settled in to begin to enjoy what we thought would be a ‘relaxing’ evening.  Unfortunately, one of the lead stories that the program featured involved the dangers of ‘button batteries’.  These batteries are especially dangerous to small children, because, as I learned from the show, the electrical current of the battery, once stuck in the esophagus, literally burns through the tissue surrounding it, causing holes in the esophagus.  They are also, unfortunately, very easy to get stuck in a child’s throat.

My mind starting racing; “OK, what products do we have in the house that are powered by button batteries?”  My concern was well-justified, as the vast majority of these tragic incidents occur to children under the age of four.  Scouring the internet this morning, I found several articles warning the parents of small children about dangers they should heed.  Sadly, I also saw blogs from the parents, in which they recount how they lost their child because of such a tragedy.  These products are not the subject of recalls, mind you.  These are batteries found in everyday products that you may have in your home.  The damage can be permanent and may effect your child’s ability to eat and drink permanently.

I found a warning on-line from the Consumer Product Safety Commission (CPSC), going all the way back to March of 1983, almost 30 years ago:

Technologic advances in electronic miniaturization have increased the availability of miniature (button) batteries in homes..in watches, calculators, cameras, hearing aids, and games. Although the vast majority of these button batteries, when accidentally swallowed, will pass through the person without any problem, occasional severe complications and even fatalities have been reported. Batteries may become lodged in the esophagus or intestine, slowly leaking alkaline electrolytes and causing an internal chemical burn.

Battery ingestions are preventable. Important prevention and treatment information is available based on preliminary results of a National Button Battery Ingestion Study conducted by Dr. Toby Litovitz, director of the National Capital Poison Center, of 62 button battery ingestions reported to the National Capital Poison Center in the past 9 months, 59% involved batteries that were left out loose rather than properly discarded or stored; 39% of the batteries were in the product they were intended for, and removed from the product. Half of these batteries were in hearing aids.

Fast forward to the present, and the warnings are all over the place.  In a recent article from examiner.com out of Baltimore, the urgency of getting the button battery out of the child as soon as possible is emphasized, due to how quickly damage can occur to the child’s throat:

The research also found there is only a two hour window to get the batteries out when lodged in the esophagus, which is less time than previously reported. Delayed removal can result in serious injuries such as tissue tears, burning, and internal bleeding .

Where can these batteries be found, and what can we do to help safeguard our children? A recent Reuters article provides us with some guidance:

They warn parents to keep not only loose batteries out of children’s reach, but also the household products that contain the batteries. In about 62 percent of cases where a young child swallowed a button battery, the child fished the battery out of a household item.

For an additional barrier, the researchers advise parents to place strong tape over the battery compartment of all household products.

They urge extra caution with any 20-mm lithium cell batteries, which can be recognized by their imprint codes — usually CR2032, CR2025 or CR2016.

On a final note, another danger is that doctors sometimes misdiagnose the injury, as the symptoms can be non-specific at times:

The current study found that in the majority of fatal or severe injuries, no one had seen the child swallow the battery. And because the symptoms of poisoning are non-specific — such as fever, vomiting, poor appetite and lethargy — doctors often initially misdiagnosed the problem.

Of course, the key is not to let your child get a hold of these ‘button batteries’ to begin with.  We strongly urge you to check your homes for these products and to take the appropriate steps to safeguard your family.  We are also again providing the link for the CPSC, as we have previously done so many times in our website‘s blog, for additional follow-up information.