Archive for the ‘Medical Procedures’ Category

Ovarian Cancer – five tips to make sure you get the medical care you need

Wednesday, May 11th, 2011

Did you know that more than 21,000 women are diagnosed with ovarian cancer in the U.S. each year? An astonishing 15,000 women die from ovarian cancer each year. Despite numerous advances in healthcare, the mortality rate for ovarian cancer has not improved in the last 30 years. Simply put, ovarian cancer is the deadliest of all gynecologic cancers. If the cancer is diagnosed in its early stages (i.e. before it spreads to other organs), the five-year survival rate is about 93.8%. However, if it the cancer is diagnosed in its later stages, the five-year survival rate is about 28.2%.

There is no question that ovarian cancer is quite deadly and that early diagnosis and treatment is key for survival. There is an abundance of information about ovarian cancer online and in other written sources. Simply put, take the time to familiarize yourself with the symptoms of this terrible disease. Let’s share with you some information, which I believe can make a difference. Call it a male lawyer’s perspective, if you will. I’ve seen what happens when early detection should have happened, but tragically did not.

1. Examine Your Medical History

Whenever the possibility for ovarian cancer exists, consider your medical history as you discuss your symptoms with your physician. If you are having symptoms consistent with ovarian cancer, take the initiative and discuss your symptoms and history with a gynecologist as opposed to your primary care physician. Make sure to tell your physician if you have any cancer history. Don’t forget to include information about any family history of cancer (parents, siblings, etc.). Of particular importance is any history of breast or ovarian cancer, although any cancer history is relevant. Unfortunately, women with a personal or family history of ovarian cancer or breast cancer are at a higher risk.

2. Understand and Appreciate Your Symptoms

Although your physician is likely to talk to you about ovarian cancer, it is always a good idea to familiarizer yourself with the signs and symptoms of ovarian cancer before your doctor’s appointment. Many of the symptoms of ovarian cancer overlap with the symptoms of cervical cancer. Therefore, if you are experiencing symptoms of cervical cancer, you and your physician should also discuss the possibility of ovarian cancer. We have seen cases were a physician will consider one or the other but not the possibility of both cancers. Here are some of the more common symptoms of ovarian cancer:

-          Irregular uterine bleeding

-          Abdominal  and/or pelvic pain

-          Abdominal fullness or bloating

-          Fatigue

-          Unexpected weight loss

-          Fatigue

-          Headaches

-          Frequent urination

-          Low back pain

Watch this video for more information about symptoms of ovarian cancer:

httpv://www.youtube.com/watch?v=fH9N4auMblE

 

Watch this video for more information about symptoms of cervical cancer:

httpv://www.youtube.com/watch?v=HHA_0HsjeBI&feature=related

3. Is it a solid mass?

If your radiographic studies reveal a mass, make sure that you get a clear answer as to whether the mass is solid or fluid-filled.  A fluid filled mass will typically turn out to be a cyst. It could also be a blocked fallopian tube (i.e., hydrosalpinx, hematosalpinx, pyosalpinx). Generally speaking, a fluid filled mass is less likely to be malignant. However, if your radiographic studies reveal a solid mass, especially one that arises from an ovary, the possibility of ovarian cancer must be seriously considered. If you are found to have a solid mass, talk to your gynecologist or primary care physician about consulting with a surgical oncologist.

4. Should you have a CA 125 blood test?

CA 125 is a protein. It is a tumor marker or biomarker for ovarian cancer because it is more prominent in ovarian cancer cells. The CA 125 test is a test designed to test the levels of CA 125 in a patient’s blood. Elevated CA 125 levels can be indicative of ovarian cancer. If your CA 125 levels are elevated, you and your physician should seriously consider the possibility of ovarian cancer. An elevated CA125 should prompt your physician to order additional radiographic studies, including a CT of the abdomen and pelvis, an ultrasound of abdomen and pelvis, a PET scan or even a CT pyelogram. You should also consider consulting an oncologist or a surgical oncologist. If you are found to have a solid mass and your CA 125 level is elevated, time is of the essence for further investigation and surgical intervention.  Ask your doctor about other tumor markers that can be tested.

5. Who is reading your ultrasound?

Many patients who present to their gynecologist with symptoms of ovarian cancer will initially undergo an ultrasound. A great number of gynecologists will themselves perform and interpret the ultrasound. Here is the problem. With all due respect to gynecologists, they are not trained ultrasonographers or even radiologists! Ultrasounds can be particularly difficult to read. This can be due to the patient’s position and, more frequently, the size of the patient. In heavier patients, a pelvic ultrasound can be quite limited if one is trying to visualize the ovaries, discern the presence of mass, or determine whether the mass is solid or fluid-filled. So, if your gynecologist is the only person to read your ultrasound, the result is potentially quite devastating. The mass could remain undiagnosed, and you may be told to come back if your symptoms get worse. The ultrasound may be interpreted as limited, and, for whatever reason, your gynecologist may simply neglect to order a more sensitive study (i.e. a CT scan). Instead, he or she may choose to monitor you for any further deterioration of symptoms.

In yet another instance, if the ultrasound is limited, a solid mass may be confused for a fluid-filled mass. Under these circumstances, you may be asked to follow-up in six months. The problem with all of these permutations is delay, and you cannot afford delay with ovarian cancer. Make sure that your radiographic studies, whatever they may be, are read by a skilled specialist in the interpretation of whatever study you undergo.

As we always say, be your own patient advocate and be an informed patient. Be an active participant in your medical care by being informed and by demanding the care you require. Having an understating of the types of mistakes that can be made during medical treatment is simply prudent.

Please share your familiarity or experience with ovarian cancer treatment. What do you think women should watch out for should they find themselves afflicted by this terrible disease?

For more information, see our other blogs:

Ovarian Cancer – Early Intervention is Key, What You Must Know…

New study links gene to ovarian cancer and may assist in early detection 

Ovarian Cancer – The Smear Test Won’t Tell You Much

 

Image from cancersyptomspage.com

Four Tips For Getting the Medical Care You Need When You Are Having An Asthma Problem

Wednesday, May 4th, 2011

Did you know that approximately 20 million Americans suffer from asthma?  Every day, about 40,000 of them miss school or work because of this condition. Each day, approximately 30, 000 experience an asthma attack.  About 5000 patients end up in the emergency room. Asthma is also the most common chronic condition among children. Can there by any doubt it is a very serious and potentially deadly medical condition that needs equally serious understanding and attention? The good news is that with proper education and treatment, most asthmatics have active and productive lives.

Bronchospasm and inflammation: the key features of asthma

This chronic airway disease has two primary features: bronchospasm and inflammation. Bronchospasm refers to the mechanism by which airways become narrower. In asthmatic patients, the muscle within the wall of the airway contracts, thus narrowing the lumen (a cavity or channel within a tubular structure) of the airway and causing respiratory obstruction. Inflammation refers to the process by which the wall of the airway becomes thicker in response to inflammation, which also causes the lumen to narrow and produce respiratory obstruction. Bronchospasm is usually treated with bronchodilators such as Albuterol; whereas, airway inflammation is treated with corticosteroids. These two characteristics vary from patient to patient. Most asthma patients have elements of both bronchospasm and inflammation.

If you suffer from asthma, keep in mind that you are the one who best understands just how your problem manifests. You alone are in the best position to provide information to health care providers in order to alert them about a possible asthma exacerbation. This is particularly true when one considers that a physician may have relatively poor knowledge regarding management practices, social background and trigger factors of asthma, among other things.  In part, the difficulty in diagnosing asthma stems from the wide variability in its presentation. Any given patient with this condition can have some or all of the classic asthma symptoms. Asthmatics can have mild deterioration or a severe attack and anything in between.  Therefore, if you have asthma, you must be proactive and communicate all the information you can to your health care provider. To help you have “talking points” when you are having this discussion, you may want to consider including the following topics the next time you see a doctor about your asthma:

1. Appreciate  Your Unique Symptoms

Asthmatic patients will often present with a cough, chest congestion/chest tightness, wheezing, and shortness of breath. Some of these symptoms may be more pronounced than others. The symptoms can change or get worse over time. Some patients may present with only a cough. Depending on the severity of the asthmatic attack, some patients may even present with normal vital signs. On other occasions, some patients could have normal breath sounds and no wheezing or shortness of breath.  For these reasons, you must carefully identify those symptoms, which are characteristic of your asthma exacerbation.

2. Give Your Physician a Complete History

Once you have identified what defines your asthma attacks, make sure to communicate the complete history of your symptoms to nurses and physicians taking care of you.  Tell them when you began to experience symptoms. If you think you are having an asthma attack, say so.  If you had been experiencing asthma symptoms, but which happen to be gone at the time of your doctor’s visit, talk about your recent problems as well. If you are taking asthma medications, identify all medications, the dosage, and the method by which you administer those medications (inhaler vs. nebulizer), your frequency of use, and most importantly, advise your doctor if your symptoms are relieved when you use those  medications. Talk about each of your symptoms, identifying their pattern, triggers, severity, and whether they are relieved by any medications.  Tell your doctor if the quality of your life is impacted by your asthma symptoms.  You may also want to inform your doctor about previous asthma exacerbation, how they presented, and whether you sought medical attention. Whatever you do, don’t assume that the nurse or the doctor will spend the time to question you extensively and get this very important information from you. Take the time and the initiative to tell them yourself.

3. If You Are Concerned About Your Condition, Ask For a Peak Flow Measurement

If you present with symptoms and your doctor rules out asthma without utilizing some objective measure of your respiratory ability, you should be very concerned. Remember that many of the symptoms of asthma can be associated with other non-asthma medical conditions. For example, a cough can be associated with asthma, but it can also be indicative of a cold. To avoid any ambiguity in what you may be suffering from, your doctor should perform a peak flow test. This test is performed with a peak flow meter, which measures a person’s maximum speed of expiration (breathing out).  It is a non-invasive test extremely easy to perform.  The test can objectively identify a respiratory obstruction. Demand this test if you are concerned about your condition! It could save your life.

4. If You Are Found to Have a Respiratory Obstruction, Don’t Leave Without Getting Treatment

If you are found to have a respiratory obstruction of any kind, do not leave your doctor’s office or the emergency department without receiving medical attention.  Generally speaking, you should be given albuterol, which is a bronchodilator. Your peak flow should then be reassessed after each albuterol treatment. Frequently, Albuterol is administered several times per hour with peak flow measurements taken after each treatment to determine your response to the medication. If you continue with a respiratory obstruction, corticosteroids should be considered and administered where indicated.  If you persist with a respiratory obstruction, additional steroids and bronchodilators may also be needed. You may even need to be hospitalized. Whatever you do, don’t leave your doctor or the emergency room if you continue to have a respiratory obstruction.

What’s your story?

If you have asthma, share with our readers the unique pattern of your symptoms.  Your information may well help others who suffer from this condition. Remember, there is not a uniform pattern of signs and symptoms with asthma. They can very widely from patient to patient.

If you would like to learn more about asthma, I strongly recommend reading the Asthma Prevention Guidelines published by the National Heart Lung and Blood Institute.  This publication is comprehensive and very informative. As we always say- the more informed you are about your own health, the better your chances will be in getting the right care.

 

Image from morningsundesigns.com

Medical Second Opinions: An Under-utilized Option for Patients

Monday, May 2nd, 2011

Today’s medical world is vast with various technologies, treatments and options.  So, if a patient is diagnosed with a medical condition, and doctor A recommends treatment A, what keeps the patient from seeking a second opinion? This is an interesting phenomenon.  After performing intake summaries and client interviews for quite a while now, it still amazes me how many people have bad outcomes from surgery simply because they never requested a second opinion. Second opinions are not simply reserved for surgery, though; cancer treatment options, medical therapies for chronic conditions like rheumatoid arthritis or inflammatory bowel disease, chiropractic care of chronic back or neck pain are some other conditions that, in my mind, scream for a second opinion!

Having practiced medicine for 13 years, working with physicians from all specialties, I can honestly say that doctors are not gods. They are human beings, no different than you or me, and human beings are prone to prejudice and errors. Granted, physicians go through a lot of education and training to perform their daily duties, but location of training, timing of training and educational mentors play a huge role in shaping the decision-making process of these humans.

Inherent limitations that can affect physician recommendations

For example, the latest technology for prostatectomy has been the DaVinci procedure, using minimally invasive robotic technology to surgically remove the prostate.  Operation of the robotics involves manipulation of “joysticks”, much like video-gaming. No offense, but if your particular urologist is 60 years of age or older, what are the chances that this particular surgeon is as adept with these skills or technology as a 30-year-old urologist?  Special training is required for use of these robotics, and not all hospitals even have the technology available. Therefore, one’s choices are automatically limited, and a minimally-invasive robotics-assisted procedure may not even be an option! A second opinion by another urologist at a different facility might be able to provide that option. A similar situation would be the use of gamma knife surgery for removal of brain tumors; it is not always an option available based on the facility or the neurosurgeon providing the consultation.

Can recommendations be limited by specialty?

Another example has to do with medical specialty affiliation. If one is trained as a surgeon, he/she focuses on the technical removal or repair of abnormal body parts. If one is trained in radiation-oncology, the focus would be the various radiation technologies available for treatment of disease. If one is a medical oncologist, chemotherapy protocols for the particular neoplastic condition would be the focus.  So who ties all of this together?  First of all, is the tumor even operable? Is the patient a good candidate for surgery? Should one try radiation first to shrink the tumor, then follow it with an operation? Is chemotherapy the way to go, but which regimen of drugs is really appropriate? These are very technical and complex questions. Should one leave the ultimate recommendation up to one specialty physician?

Suggested approach to the problem

For me, it would be a little more comforting to get the same overall recommendation from two independent physicians. What if the opinions differ?  A third opinion? – or, simply focus on the discrepancies with direct questioning of the two physicians and find out the rationale for the recommendation being made. You do not know how many times I have heard, “I trusted my doctor.” I ask you, if your car was making a rattling noise but seemed to be running okay and a mechanic told you a new transmission was necessary at the cost of $1800, would you get a second opinion?

Don’t let fear or reprisal get in your way

One of the main reasons for fear in seeking second opinions is anticipated disapproval and potential retaliation by the first physician or fear of a change in the patient-physician relationship.  I pose to you the following:  if a physician has done his/her research regarding the condition and is confident is his/her recommendation, then he/she should not fear the opinion of a peer. If that opinion differs, it should be reviewed for accuracy and appropriateness because it might just be a viable option not previously considered. If the physician is “offed” by the patient’s search for a second opinion, that physician thinks way too highly of himself/herself; keep in mind that this is about the patient who has a condition that requires treatment, not the physician’s integrity or ego. It is my firm opinion that physicians should be proud of those patients who advocate so strongly for themselves and seek to be educated about their condition.  Education leads to a better understanding of the disease process, better expectation of the “road ahead,” and better patient compliance with medical therapies. Retaliation is prohibited by the medical code of ethics; if there is a retaliatory action, the state’s Medical Board should be notified and prompted to investigate.

Beware of the on-line second opinion approach!!!

Recently, multiple facilities have offered a “second opinion service” via the internet. A patient submits his/her medical condition along with various lab studies and other diagnostic imaging (CT scans, x-rays, MRI scans, etc.) for review over the internet; an opinion is provided based on these facts!  What this really doesn’t take into consideration is the patient!  Patients are people – human beings with emotions, physical limitations, families (or not), previous histories and other underlying health conditions. One of the things I was taught in PA school was to treat the patient and not the numbers!  Not all patients are surgical candidates.  Not all patients can emotionally or physically tolerate some of the chemotherapy protocols. Someone might look good on paper with great blood parameters, vital signs, etc., but in person, one’s assessment changes dramatically.  These virtual second opinions may have their place in certain situations, but I generally have to question the validity of such an assessment.

A “real-life” story

I leave you with a quick summary of a case:  Mr. B was a 40-something, physically fit male professional, who loved to work out and exercise. He developed some mechanical back pain for which he sought treatment. An MRI scan revealed an incidental finding of small spinal cord glioma in the low back. Clinically, there was no evidence to support that this incidental finding was in any way related to Mr. B’s pain. He sought the advice of a neurosurgeon, who immediately wanted to operate. Well, if research had been done, these particular tumors are 99% benign, very slow-growing and can often be monitored for 10 to 20 years before surgery might even be necessary.

Mr. B followed the advice of the surgeon and underwent a resection of this small tumor. The surgery required resection of the S1 nerve root, which affects sensation in the genital region and anus; Mr B was now impotent and had problems with bowel movements in addition to a chronic burning sensation in his genital region. A second opinion might well have saved Mr. B a lot of pain, permanent erectile dysfunction and money required to undergo alternative methods for conception. He’ll never know now.

Have you or someone you know gotten second opinions before making a decision about an important medical procedure? What’s your approach? Have you ever received different opinions about how to treat a condition? How did you resolve this situation? Any tips for others?

Image: Wellsphere.com

Update: After posting Theresa Neumann’s piece this morning, I came across a somewhat related post on KevinMD.com entitled Marcus Welby and the relentless growth of specialization. The author, Jan Henderson, PhD, raises some very interesting thoughts about what I would call the “over-specialization” of medicine. She provides the following quote of Dr. Welby from very first episode of this TV show of years gone by, which – to me – supports one of the concerns raised by Theresa in her blawg:

… I hope some of you will go into general practice. For if you don’t, where will a patient turn who doesn’t know that he has an orthopedic problem? Or a neurological problem? Or a psychiatric problem? Or a nutritional problem? But who only knows that, in lay terms, he feels lousy.

Just some food for thought you might enjoy.

Brian Nash (editor of “Eye Opener”)

Laughing Gas Making Its Way Back Into The Labor And Deliver Department

Thursday, April 21st, 2011

According to a recent article published by MSNBC, laughing gas or nitrous oxide is making its way back into labor and delivery units in American hospitals. Although laughing gas has long been used as a pain relief in various countries, including Canada and the U.K., it has lost its popularity in the U.S. Well, maybe not for much longer.

It appears that a number of hospitals are now considering making laughing gas available as a pain relief measure for women in labor. A hospital in San Francisco and another in Seattle have been using laughing gas in their labor and delivery units for a while. Hospitals like Dartmouth-Hitchcock Medical Center plan to offer laughing gas to laboring mothers in the immediate future. Dartmouth-Hitchcock’s plan is currently being reviewed by the federal government, and arrangements are presently being made for the procurement of delivery equipment for laughing gas. Vanderbilt University Medical Center may begin offering laughing gas as well later this year.

History

Laughing gas is not a new pain relief method. Its use had become very common in hospitals when Joseph Thomas Clover invented the gas-ether inhaler in 1876. Particularly, its use in the labor and delivery setting had been very common before the introduction of epidural and spinal anesthesia. Because laughing gas is unable to eliminate pain to the same degree as epidural or spinal anesthesia, it simply could not compete with the more sophisticated pain relief alternatives, which entered the marker in the 30s and 40s.

What is laughing gas?

Nitrous oxide, commonly known as laughing gas or sweet air, is a chemical compound with the formula N2O. It is an oxide of nitrogen. At room temperature, it is a colorless non-flammable gas, with a slightly sweet odor and taste. It is used in surgery and dentistry for its anesthetic and analgesic effects. It is known as “laughing gas” due to the euphoric effects of inhaling it, a property that has led to its recreational use as a dissociative anesthetic.

Laughing gas as an important pain relief alternative

Although laughing gas can only take the edge off pain, it just might be an important alternative to other more conventional pain relief methods. The patient does not have to rely on an anesthesiologist to administer the gas. The patient can herself choose how much gas to administer at any time. The effects of the gas are not long-lasting. Therefore, the patient does not have to recover in a post anesthesia care unit. Importantly, there is no associated loss of sensation and motor function during the delivery process. As such, the gas does not interfere with the woman’s ability to breath and push during labor. Laughing gas is also not known to have any adverse effects on the baby in utero.

The administration of laughing gas does not require any invasive medical procedures. By contrast, consider epidural anesthesia: An epidural requires that an epidural catheter be threaded into the epidural space, which is only about 2 mm wide. Any mistake and the consequences can be catastrophic. Epidurals have been known to cause spinal cord injury secondary t0 toxicity, spinal cord infarcts, severe hypotension, paraplegia, epidural bleeding, and even death. None of these complications are associated with the use of laughing gas.

: httpv://www.youtube.com/watch?v=1TO4sOgiIeU]

According to Suzanne Serat, a nurse midwife at Dartmouth-Hitchcock Medical Center:

We have a number of people who don’t want to feel the pain of labor, and nitrous oxide would not be a good option for them. They really need an epidural, and that’s perfect for them. […] Then we have a number of people who are going to wait and see what happens, and when they’re in labor, decide they’d like something and then the only option for them is an epidural but they don’t need something that strong. So they would choose to use something in the middle, but we just don’t have anything in the middle.

Nitrous oxide may just prove to be that middle option for many women who prefer to give birth without the use of powerful and potentially dangerous analgesic/anesthetic agents. If you are an expectant mother, ask your obstetrician if nitrous oxide is a pain relief option that may be available to you during labor.

Image from cartoonstock.com

For more information about epidural anesthesia and epidural complications, you may want to read these posts too:

Having an epidural when you deliver your baby? 3 Questions to ask the doctor!

5 Questions to Ask Your Obstetrician Before You Go to the Hospital

Epidural Analgesia – What Should an Expectant Mother Consider? What are the risks?

Robot Anesthesiologists?

Tuesday, April 19th, 2011

robotic intubationFor anyone contemplating serious surgery, it can be a scary endeavor. From going through it myself and talking to others, I know that the main fear we have going into it is that the surgeon will make a mistake during the surgery, or that we will develop serious complications such as a hematoma, infection, etc. that leads to death or paralysis. While these are very real risks of many forms of surgery, there is another aspect of surgical procedures that gets less attention from patients – the anesthesiologist. While it may get little notice from patients, anesthesiology is a highly complex field of medicine in which doctors (and certified nurse anesthetists) train for years to be able to do it well. This post will focus on just one aspect of anesthesiology known as intubation, and a new development in robotics that may improve the procedure.

What is intubation?

At its most basic, intubation is the process by which the anesthesiologist places a thin plastic tube into the patient’s windpipe to maintain an airway or to facilitate mechanical ventilation. While this is done in a variety of serious medical situations, it is almost always done during major surgery when the patient is under general anesthesia. During such surgery, the patient is rendered unconscious and is unable to breathe on his or her own. Therefore, the anesthesiologist has to essentially breathe for the patient during the surgery, either using a ventilator or sometimes compressing a bag that replaces natural breathing. The process of intubation allows this artificial breathing to take place. Because intubation itself is a painful procedure (remember – a tube is being inserted far down your throat), the patient is usually given paralytic drugs (drugs to induce paralysis) before intubation. This is a key point we’ll come back to later.

Risks of Intubation

While it may sound as simple as sliding a tube down the throat, intubation carries its own risks separate and apart from the risks of anesthesia itself (risks from anesthesia can include death, paralysis, brain damage and a whole host of other less serious injuries). With intubation, there are minor risks such as chipped teeth, lacerations in the gums and sore throat. However, there are many more serious risks as well, including perforation of the trachea, mistakenly placing the tube down the esophagus (a more common occurrence than you might think), aspiration of stomach contents, vocal cord injury, decreased oxygen and elevated carbon dioxide, and nerve injury. Intubation is a serious procedure that requires a high degree of skill and training to do it well and safely.

What if the tube does not get placed properly?

Inability to secure the airway is a major problem in intubation. To understand why, you have to remember that before the tube is placed, the anesthesiologist paralyzes you with drugs. Therefore, before the tube is placed, you stop breathing on your own. It is then critical that the tube be placed quickly and accurately to ensure that you don’t suffer from a lack of oxygen (or ventilation – the exchange of oxygen and carbon dioxide). So what happens when the anesthesiologist has trouble getting the tube in? It just so happens that I have some personal familiarity with that scenario.

A few years ago I had back surgery. The surgery itself was not complex as far as spine surgeries go (it always amazes me how surgeons are able to describe cutting open your back and operating on your spine as casually as they might describe changing a light bulb). It essentially consisted of trimming off a small piece of disc that was pressing on my spinal cord and causing pain to radiate down into my leg and foot.  I was in and out of the hospital the same day, but of course I was under general anesthesia so I had to spend a couple of hours in the Post Anesthesia Recovery Room (PACU) to make sure that I was not suffering from any ill effects of the anesthesia. While waking up, and still groggy, the anesthesiologist walked up to me and said, “I just want to let you know – you were really hard to intubate. If you ever have surgery again, be sure to tell your doctor that you’re really hard to intubate.”

I asked the doctor what he meant by that. He told me that because of the anatomy of my mouth and throat, he had had a really difficult time getting the tube into my airway. Keep in mind, the tube was placed down my throat after I was given drugs to paralyze me. Even in my post-anesthesia addled state, I knew enough to ask the obvious question – what would have happened if he couldn’t have gotten the tube down in time? He was casual in his response. “Oh, we would have given you drugs to wake you back up.” How comforting. My next thought was, “Maybe you could have checked my anatomy out before you gave me paralyzing drugs.” I didn’t ask that because I am sure they did check me pre-operatively.  That is standard procedure before giving anesthesia to make sure that the anesthesiologist knows the patient’s anatomy and can anticipate problems. Apparently, my anatomy was a little more vexing than he had bargained for. However, he was finally able to get the tube in and the surgery went well.

The use of robotics

Because of the ever-present risk of serious complications, researchers are always working on improving intubation to minimize risk. It has always been a hands-on procedure that depended on the skill of the individual performing it. Now we may be moving into a whole new world of intubation thanks to advances in robotics.

Medical News Today is reporting that Dr. Thomas Hemmerling of McGill University and his team have developed a robotic system for intubation that can be operated via remote control. According to Dr. Hemmerling:

The [device] allows us to operate a robotically mounted video-laryngoscope using a joystick from a remote workstation. This robotic system enables the anesthesiologist to insert an endotracheal tube safely into the patient’s trachea with precision.

The system is still in development. It has been widely tested with mannequins that mimic human anatomy, and clinical testing on patients has now begun. Dr. Hemmerling hopes that the new device will allow anesthesiologists to intubate patients using less force and higher precision, which should help to improve patient safety. Even with the use of robotics, I would think that intubation, including pre-operative assessment of individual anatomy, is going to require close hands-on involvement in order to ensure that it is done safely and properly, but it is always exciting to see what was once science fiction being used in real-life surgeries.

What you can do

While robotic anesthesiology is still down the road for most of us, there are still things you can do to minimize your risk of injury. Before agreeing to surgery, most of us do a good job of vetting our surgeon – how experienced he or she is, how many similar procedures he or she has performed. How many times have you heard a friend describe his or her surgeon as “the best?” Yet virtually no one who has been a patient – at least in my experience – makes any inquiry into the experience level of the anesthesiologist, even though a mistake by this person can render you paralyzed or brain-dead (or even dead) in a matter of minutes.

If you are planning on undergoing serious surgery, I would encourage you to discuss the anesthesia care with your surgeon. Find out ahead of time who your anesthesiologist is going to be (if that’s possible), and discuss your situation with that person. No doubt you will be evaluated by the anesthesiology team before your surgery, but it may well be the same day as your surgery, and it will feel like just another routine matter like signing a few forms. Keep in mind, however, that anesthesiology is just as important as the surgery itself. Stay informed and ask questions. Treat your pre-operative session with the anesthesiologist as if your life and health were depending on it – it just may!

And as for robotics, I’m curious what your comfort level would be if your doctor suggested using a robot to intubate you? Would you be willing to try the procedure, or would you prefer the traditional hands-on, human approach?

Image from “Today’s Medical Developments”

Week in Review: If you missed this past week’s blogs – catch up!

Sunday, April 10th, 2011

This past week was a busy one for our bloggers. It was also a very busy week in our law practice. Over the last two months, we have also had two new lawyers join us – Sarah Keogh and Jason Penn. Sarah has contributed a number of posts already. Jason , who just started this past Monday, will soon be sharing his contributions, thoughts and comments with you as well. We’re very happy to have both of them. I’m sure you join us in wishing them a very warm welcome.

Last week our writers covered a number of topics related to health, medicine, child safety, medical technology and patient safety. We started the week off with a piece by Brian Nash on some key facts women need to be aware of when having an epidural for labor, delivery and post-partum pain relief.

Epidurals

There can be no doubt that thousands of epidurals are administered to women every day throughout this country. This form of analgesia (pain relief) has become probably the most popular form of anesthetic management and apparently is generally believed to be essentially risk free. As this week’s piece, Having an epidural when you have your baby? 3 questions to ask the doctor, reports, some literature gives the figure of complications from epidurals as high as 23% - ranging in severity from minor inconveniences, to life-long major disabilities and even death.

This particular piece was written as a result of several cases in which we have been involved when women, who had undergone an epidural, became essentially paralyzed from the waist down. We raise some questions for women to ask the doctor and suggest they just might want to ask those questions before they find themselves in the process of labor or when they are going through the recovery phase of having given birth to their baby. We believe it’s an important piece for women – and frankly for all – to read so that they have a much better idea of what they should expect with an epidural and what the risks and benefits are of this wonderful yet potentially life-altering anesthetic technique.

Shaken-Baby-Syndrome

On Wednesday, Jon Stefanuca again brought to the public’s attention a problem that is probably as old as childbirth. Everyone who has had the experience of taking care of a child – particularly a baby – knows that along with the joy of parenting comes the physical and emotional toll on parents and care-givers. The human condition makes us all susceptible to being less than completely tolerant, forgiving and gentle with little ones when we are under stress, frustrated or just plain exhausted. The response to the persistent crying can simply not be “a good shake.”

Medicine and science (and unfortunately the courtroom) have given a name to a syndrome of injury babies can suffer when that “just a good shake” approach is used. While a parent or care-giver may think it unimaginable to strike a child, they may not realize just now much harm they can do with “just a good shake.” Jon brings this information and some expert tips and tricks on how to deal with these difficult times parents and care-givers face in their everyday lives in his piece Shaken Baby Syndrome – What we all should know to prevent child abuse.

Makena: New Anti-Prematurity Drug

Thursday, Sarah Keogh reported on a relatively new drug called Makena, which has been found to help pregnant women, who have previously had a premature infant. I say “relatively” since according to Sarah’s piece, a compounding pharmacy could and was making this medication prior to the FDA giving K-V Pharmaceutical Company the exclusive rights to manufacture this drug for a period of 7 years.

Read Sarah’s piece, Makena: Drug to fight prematurity leads to major firestorm, and see what the controversy is all about. How could people possible be upset with a drug that can fight premature birth? Prematurity is one of the major causes of significant childbirth injuries such as cerebral palsy. Sarah’s blog makes it all too clear why people are upset and why the March of Dimes withdrew its sponsorship for Makena.

Medical Technology and Patient Safety

The week ended with Part II of my series on medical technology and whether all the new toys, bells and whistles of our modern healthcare system are truly advancing safe, efficient and effective delivery of healthcare. The week’s piece focuses on perhaps one of the largest advances in the healthcare industry – electronic medical records (EMR).

The blog, Medical Technology and Patient Safety – Part II – EMR’s (electronic medical records), brings a lawyer’s perspective to this topic. Much has already been written – and frankly will continue to be written – about EMR’s by the medical profession. Controversy has filed the pages of journals and at times probably slowed traffic on the internet (okay – maybe that’s a bit of an exaggeration) since this new marvelous technological advance was rolled-out in our medical institutions.  Those writing and fighting about it have been the end-users themselves – the medical professionals, who have to deal with the issues and flaws that have surfaced with this wonderful new technology. I thought it was about time to tell you how this plays out by another end-user – the lawyer who now deals with EMR’s. This piece is also intended as the foundation for what we as lawyer have seen play-out in terms of patient safety and health as a result of EMR implementation.

Sneak Peak of the Week Ahead

I anticipate that next week we’ll be seeing Jason Penn with his first blog on a recent report about numerous safety violations by hospitals in our practice jurisdictions – Maryland and Washington, D.C. Mike Sanders will be bringing to our readers aN old but back-in-the-news report on super infections, which still seem to be – unfortunately – thriving in our nation’s hospitals. We’ll start off this coming week with a piece by Theresa Neumann, our highly acclaimed in-house physician’s assistant expert, on spinal stroke. We all know about strokes that can damage the brain. Theresa will be sharing her insights on an equally devastating stroke of the spinal cord. I also suspect – shhh – that we’ll be reading more from Sarah Keogh this coming week. If the practice of law doesn’t get too much in the way, I am also hoping to share with you some real life examples – from a lawyer’s perspective – of just how EMR’s may not be advancing the causes of patient safety and health.

As with all our blogs, we sincerely invite you to not only read our thoughts and comments but to also share yours with us and our readers. Our latest stats show that around 10,000 pages are viewed by our readers and visitors every month! We sincerely thank all of you, who have taken the time out of your busy lives to read our offerings in The Eye Opener – Views and Opinions from the Nash Community. We invite you to share our posts with your friends and colleagues. Don’t forget to sign-up for easy delivery to your email inbox. Last – but certainly not least – come join our social media communities on Facebook and Twitter.

New Treatment Holds Promise for Patients With Spinal Cord Injuries

Wednesday, February 23rd, 2011

According to a recent article in Medical News Today, Functional Electrical Stimulation (FES) can significantly reduce disability caused by spinal cord injuries. The study was originally posted on line in the Journal of Neurorehabilitation and Neural Repair.

This relatively new treatment applies small electrical impulses to stimulate paralyzed muscles. The treatment has been shown to measurably improve a patient’s ability to pick up and hold objects. Dr. Popovic and his team concluded that FES should be used in conjunction with traditional physical therapy.

To see how this works, here’s an incredible demonstration by Children’s Hospital of an FES bicycle.

httpv://www.youtube.com/watch?v=27vIfWdB3wk

Here are some key facts about this study:

  • FES therapy uses low-intensity electrical pulses generated by a pocket-sized electric stimulator.
  • Unlike permanent FES systems, the one designed by Dr. Popovic and colleagues is for short-term treatment. The therapist uses the stimulator to make muscles move in a patient’s limb. The idea is that after many repetitions, the nervous system can ‘relearn’ the motion and eventually activate the muscles on its own, without the device.
  • The randomized trial, believed to be the first of its kind, involved 21 rehabilitation inpatients who could not grasp objects or perform many activities of daily living. All received conventional occupational therapy five days per week for eight weeks. However, one group (9 people) also received an hour of stimulation therapy daily, while another group (12 people) had an additional hour of conventional occupational therapy only.
  • Patients who received only occupational therapy saw a “gentle improvement” in their grasping ability, but the level of improvement achieved with stimulation therapy was at least three times greater using the Spinal Cord Independence Measure, which evaluates degree of disability in patients with spinal cord injury.
  • Based on their findings, the study’s authors recommend that stimulation therapy should be part of the therapeutic process for people with incomplete spinal cord injuries whose hand function is impaired.
  • Dr. Popovic’s team has almost completed a prototype of their stimulator, but need financial support to take it forward. Dr. Popovic thinks the device could be available to hospitals within a year of being funded.One limitation of the study is that the research team could not get all participants to take part in a six-month follow-up assessment. However, six individuals who received FES therapy were assessed six months after the study. All had better hand function after six months than on the day they were discharged from the study.
  • Dr. Popovic stresses that FES therapy should augment, and not replace, existing occupational therapy.
  • Another study, now underway, will determine whether stimulation therapy can improve grasping ability in people with chronic (long-term) incomplete spinal cord injuries.

If you or a loved one suffer from spinal cord injury, please consult with a physician about FES. In conjunction with physical therapy, this non-invasive medical procedure promises tremendous benefits to patients with spinal cord injuries. If you are aware of other studies or treatment relating to rehabilitation from spinal cord injuries, we encourage you to share your knowledge with our readers.

Baltimore Abortion Ordinance Declared Unconstitutional – How Did We Get Here and Why?

Saturday, February 5th, 2011

Pro-Life and Pro-Choice Advocates

Last April, we posted a blog regarding a Baltimore City ordinance, which required local crisis pregnancy centers to post signs in their clinics disclosing that they did not offer abortion or birth control services if, they in fact, did not offer such services. Because of this requirement, many clinics chose to post separate notices informing the public about clinics that offered abortion services. Consequently, the Archdiocese of Baltimore, filed a lawsuit in the Federal District Court, seeking to have the ordinance declared unconstitutional.  One of its arguments was that the City should be prohibited from compelling speech by requiring the clinics to post signs.

On January 28th, 2011, District Court Judge, Marvin Garbis, ruled that the ordinance violates the First Amendment of the U.S. Constitution and, as such, is unenforceable. In his opinion, Judge Garbis wrote: “Whether a provider of pregnancy-related services is ‘pro-life’ or ‘prochoice,’ it is for the provider — not the Government — to decide when and how to discuss abortion and birth-control methods.” According to the opinion, “[t]he Government cannot, consistent with the First Amendment, require a ‘pro-life’ pregnancy-related service center to post a sign as would be required by the Ordinance.”

The dynamic of this litigation is fascinating, revealing nonsensical and unpredictable aspects of the abortion debate.  One could argue that the original passing of the ordinance was fueled by an underlying “pro-life” attitude.  After all, why would the City require clinics that don’t offer abortion services to publically state that they don’t offer abortion services? My personal opinion is two-fold: 1) to discourage individuals in need of abortion services from seeking abortion services, and 2) to reveal to the public the number of clinics that don’t offer abortion services in order to paint a picture that the public is generally pro-life (this is particularly true because the ordinance did not require clinics offering abortion services to post notices that they offered such services).

Interestingly, the ordinance backfired. Some of the clinics required to disclose that they did not offer abortion services chose to inform the public about other clinics where abortion services are available. There is nothing wrong with that, right? Well, apparently the Archdiocese did not think so, and, in my personal opinion, here is the real reason why: As soon as it became apparent that many of the clinics could simply choose to post notices about other clinics, which offered abortion services, it also became apparent that the ordinance was de facto prompting free advertising for abortion services all over the city.

I can’t imagine that the Archdiocese was too thrilled about that. Hence, the litigation ensued and the opponents of the ordinance prevailed on an argument, which is commonly and usually made by the “pro-choice” side of the abortion debate. At the heart of Judge Garbis’ opinion is the notion that the government should not legislate morality or religion. On January 28th, the Archdiocese and other “pro-life” groups prevailed on an argument, which has undermined and discredited the “pro-life” position for decades. How ironic!

Have you have been following this litigation in Baltimore City? What are your thoughts? Was Baltimore’s ordinance misguided or spot-on? Will Judge Garbis’ decision be reversed or upheld on appeal?

Photo from foxnews.com

Confusion with Advanced Directives: Palliative Care, End-of-Life & Hospice Care

Tuesday, December 21st, 2010

In a previous blog, I raised the issue of “Advanced Directives” and how, according to a Medscape physician survey, physicians do not always honor these legal documents.  One of the “excuses” cited the definition of futility in treating a terminal medical condition, arguing for palliative care as opposed to withdrawal of care.  Obviously, confusion exists amongst these providers as to what constitutes comfort care versus unnecessary prolongation of life and/or exposure to unnecessary procedures in a patient with a terminal condition.

Palliative, End-of-Life and Hospice Care

Palliative care is essentially comfort care.  To “palliate” means to “ease” or “make less severe” – therefore, medical care that is designed to palliate symptoms of a particular disease is care designed to ease or lessen the severity of symptoms associated with that disease.  It can be in an acute condition, a chronic condition or even a terminal condition depending on the stage of the illness.  Some of the symptoms often palliated are nausea and vomiting (chemotherapy, cirrhosis), anorexia (cancers, AIDS), pain (rheumatoid arthritis, cancers), shortness of breath (COPD/emphysema, interstitial lung disease), dizziness (Meniere’s disease, multiple sclerosis), incontinence (spinal cord injuries, stroke), constipation (inflammatory bowel disease, chronic pain syndromes), and many others.  There are various treatments available for the treatment and/or management of these symptoms, but they are not necessarily curative of the underlying condition.  Some chronic conditions, like Rheumatoid Arthritis, are manageable but not necessarily curable, so the treatment rendered is to palliate/lessen the symptoms and hopefully put the auto-immune disorder into remission for a period of time.  Rheumatoid Arthritis, however, is NOT a terminal condition; patients usually die of complications or other co-morbidities.  Palliative care can also incorporate a variety of specialties with overall coordination of care that involves communication with the family, spirituality and emotional support.  Palliative care is a critical component of end-of-life and Hospice care.

End-of-Life care is a well-coordinated approach to end-of-life issues when a condition is deemed terminal, such as incurable metastatic cancer, end-stage multiple sclerosis or even liver cirrhosis when organ transplant is not an option.  Life expectancy can vary widely, with physician guestimates being greater than 6 months (as much as one year or more).  End-of-life care typically incorporates palliative care to ease the symptoms of the disease process as well as counseling services, emotional support and even spiritual support.

Hospice care is end-of-life care, incorporating palliative care, reserved for the last 6 months of life or less.  Care is shifted from curative therapies to pain management and ease of other symptoms of illness.  There are many Hospice programs that offer services in a variety of locations, all of which is dependent on the patient’s and the patients’ family’s wishes. They can be rendered at home, in a nursing home, in the hospital or in a dedicated Hospice facility.  Services provided by these organizations can even include basic housekeeping, personal hygiene care, grocery shopping, and even companionship in addition to the palliative medical therapies.

Where do advanced directives come into play?

Advanced directives can affect every one of these aspects of care.  They reflect the patient’s or the patient’s medical power of attorney’s wishes regarding palliative care modalities, end-of-life care and Hospice care.

About.com’s website on palliative care offers a great example of palliative care that transitions to end-of-life and at-home Hospice care for “Aunt Tilly”.

A patriarch of the family has essentially been healthy his entire life, shoveling  snow and cutting grass into his 85th year of life.  Things shift during the 86th year, and he develops congestive heart failure which has triggered multiple falls and syncopal episodes, presumably from hypoxemia.  There are several hospitalizations to evaluate his condition with institution of multiple medical therapies/drugs to stabilize his condition.  Unfortunately, his heart is weak, and ultimately his kidneys begin to fail.  No advanced directives had ever been discussed, as with many people of his generation; fortunately, he remained of sound mind.  At first, everything was a whirlwind……medication infusions to prevent irregular heart rhythms, blood transfusions to address his anemia since the kidneys were no longer working properly to stimulate the bone marrow to make more red blood cells, and finally, dialysis???  Well, if the kidneys are not working very well, not filtering the blood to produce urine and not stimulating the bone marrow to produce RBCs, we have to fix this, right?  What was not mentioned was that blood transfusions have to be given with intravenous fluids, which then worsen the fluid overload and congestive heart failure making it even more difficult for the poor man to breathe.  Higher and higher amounts of oxygen are needed to keep him comfortable, while his body is swelling up with fluids.  So, STOP THE MADNESS!  This family patriarch, after being informed of the complicated nature of his essentially end-stage condition, opted to forego hemodialysis; he did not want to be hooked-up to a machine for 3 hours a day, 3 days a week, just to filter his blood in an attempt to garner perhaps 6 more months of life; that kind of life had no quality to it in his mind.  In addition, since the blood transfusions would only worsen his breathing, he refused any more blood.  He wanted to be kept comfortable with pain medications and oxygen which was done in the hospital; he did not want to be shocked (defibrillated) or resuscitated in any way.  Comfort measures were provided in the hospital where he was given a large, private room, and he passed away peacefully within 3 days; there were no restrictions on family visitation, and he was surrounded by those dearest to him.  A chaplain was available within minutes of his death to comfort the family and offer prayer to ease everyone else’s suffering and loss; this patriarch was already at peace and without pain.

In this particular example, it was beneficial that my family member was of sound mind to make his own decisions at the end of life with regard to blood transfusions and hemodialysis.  It would have otherwise been very difficult for the family to come to some kind of consensus.  It was also better, in this case, that he remain in the hospital since his wife was still living and would have to return to their home alone following his death; having her live in the house in which her husband of 67 years had died would have been too much for her to bear.  This emphasizes the importance decision-making while one is of sound mind.  Cancers can spread to the brain; toxic metabolites that accumulate when vital organs fail can render a patient confused or even comatose; acute strokes can also affect one’s cognitive capabilities, not to mention other organ systems (breathing, toileting, swallowing, etc.).

Advanced directives can be as precise or as vague as one desires.  It seems to me that the more detailed the directive, the less chance one encounters of a physician or care provider ignoring the directive or “interpreting” the directive in a way that confuses loved ones, exposing the patient to unnecessary procedures and/or life-extending treatments.

Have you ever had to deal with any of these issues – advanced directives, palliative care, end-of-life care or hospice care? What has your experience been? Do you have any suggestions that might be helpful to others, who may be faced with similar issues?

More on this topic soon: What constitutes a terminal condition?

Related Posts:

Advanced Directives: The Right to Die With Dignity. Does the Medical Profession Honor Them?

Making Your Wishes Known at the End of Life (NY Times article by Dr. Pauline W. Chen )

Image from mylocalhealthguide.com


CT Scans – Are You Being Properly Protected Against Radiation?

Thursday, December 2nd, 2010

According to new research presented at the annual meeting of the Radiological Society of North America, breast shields should be used for men and women undergoing CT scans of the chest/lungs. According to Terry Healey, M.D., Director of thoracic radiation at Alpert Medical School of Brown University, the breast shield is capable of reducing the level of radiation by about 30%.  This is significant considering that radiation can cause or contribute to the development of various malignancies (e.g. breast cancer, lung cancer, esophageal cancer).

Although some physicians argue that the use of breast shields may impact the quality of the CT scan (i.e., by producing artifacts such as streaks or lines making the interpretation of the study more difficult), this new research suggests that the use of breast shields does not impact the diagnostic quality of the CT scan. A breast shield is nothing more than a thin piece of heavy metal placed in front of the chest during the CT scan procedure.

Researchers studied 50 patients, who needed CT scans of the chest. Most of the patients were undergoing the study to rule-out lung cancer.  For some patient the shield was placed directly on the chest. For other patients, the shield was slightly elevated from the chest surface. Overall, some artifact was present in about 2/3 of the cases. However, in the opinion of the researchers, there were no instances where the artifact interfered with the diagnostic quality of the radiographic study.

According to Judy Yee, M.D., vice chair of radiology at the University of California: ”[T]here’s no good reason not to use breast shields. The cost is relatively low and the benefit large.”

Perhaps a larger patient population is needed for the results of this research to be more widely accepted by the radiology community. We’d appreciate anyone who has experience in this field to share their thoughts on this topic. Do such shields cause artifact that makes the study less accurate and potentially dangerous to a patient? Does the accuracy of the scan, when a shield is used, depend on which type of scanner is used or which generation of scanner is being used? Are there other techniques that can be used to protect a patient yet not run the risk of artifact “mis-read”? We’re not physicians or radiology technicians, so we welcome any insights those who are might have on this topic.

If you are concerned about excessive radiation and need to undergo a chest CT, ask your radiologist if a protective shield can be used during your CT scan. Discuss the issue and – as we always stress – take charge of your own medical care. Be an informed patient and be responsible for your own health and safety. Know what the issues, risks and benefits are and discuss it with your doctor. Then – and only then – make an informed decision.

Image from emedicine.medscape.com