b.cognosco

Why You Need To Be As Smart As Your Doctor

terrywfrazier@gmail.com — Tue, 15 May 2007 19:38:00 GMT

In August of last year a 43-year-old woman undergoing chemotherapy treatment for nasal cancer died after receiving a massive overdose of the chemotherapy drug flourouacil. According to an Incident Report (pdf) issued by the Institute of Safe Medicine Practices Canada the dose was miscalculated by two different nurses and incorrectly programmed into an electronically-controlled pump. The woman was then sent home, where the pump poured four (4) days worth of drug into her in four (4) hours.

When the woman returned to the cancer clinic to report the problem a nursing supervisor contacted the doctor on call and was told nothing could be done - there was no antidote - and the woman should be advised to call the next morning. The woman was warned of vomiting and nausea and instructed to stay hydrated.

For the next couple of days no one at the clinic paid much mind to this incident and no one advised the patient of the potential severity of consequences. On the third day someone contacted the patient and advised her to come in the next day. By the fourth day the patient was sick and returned to the clinic but there were no beds available. She was admitted the next day.

For the next two weeks this woman's body systematically destroyed itself in a rather grotesque and painful sequence of events that led to her death in ICU approximately two weeks after her admission.

This event happened in Canada, but it could happen anywhere. It could happen in every hospital or clinic I've ever been in. The problem is that we rely to much on our doctors, and our nurses, to get things right and they just don't always do so. We simply must know what they are pumping into our bodies. We must know what it is, what it does, and what the potential consequences are.
More importantly we need someone with us, and intelligent advocate, any time we undergo such a procedure because as patients we simply aren't in any shape to think straight and ask the important questions. Someone should have noticed after an hour that the woman's medicine was now 1/4 gone and stopped it. Someone should have known, and told the patient, that she was being poisoned (intentionally) and that an overdose would almost certainly be fatal.

My experience is that when you go into a hospital or clinic you are given a form to sign that says you could die. You get that for everything from having an ingrown toenail removed to open heart surgery. But the realistic outcomes are simply not the same for both cases. And the verbal instructions and warnings given by staff are designed to be comprehended by fifth graders and not raise anyone's anxiety level. The result is everyone signs the form without reading it (I'm not sure it contains anything useful anyway) and, as the report shows, we rarely get the full scoop via verbal instructions or even written discharge orders.

We have made enormous improvements in healthcare over the last 50 years, but we are just nowhere near where we need to be. Until we are we all need to educate ourselves as much as possible on what the doctors are doing to us, what the (realistic) potential consequences are, and what we should be watching for.

Why Your Doctor Should Read Wired Magazine

terrywfrazier@gmail.com — Thu, 10 May 2007 03:39:03 GMT

I’m often complaining about doctors, the archaic practices of med school, and healthcare in general. But some doctors actually get past the drudgery and pain of spending half their waking hours dealing with dysfunctional bureaucracy with enough imagination intact to actually keep getting better at what they do. How do you know if your doctor has imagination and energy for growth? Maybe they read Wired magazine, or even have a blog like Clark Venable. The sad thing is this stands out because it is so rare.

I'm a Better Anesthesiologist Today Than A Year Ago
At the end of this busy week I began to reflect on how this week was different than an average week would have been even a year ago. It was different both for me and for a significant number of my patients. Hopefully, it was as good for patients as it was for me.

For the first ten years after I finished my training I did not believe nerve blocks for extremity surgery were worth doing. Surgeons didn't want to wait for me to do them or for the blocks to 'set up.' Blocks failed a certain amount of the time. There were complications that just didn't happen when 'numbing the big nerve.'

My thoughts on all this changed, not because of a journal article or discussions with a colleague, but because of an article in Wired magazine. The Painful Truth was an article on the use of regional anesthesia to improve medical care to our wounded soldiers in Iraq and Afghanistan:

Now Buckenmaier is leading a group of army doctors and nurses determined, as he puts it, "to drag the military kicking and screaming into the 21st century." His team believes the future of wartime pain control is a new form of anesthesia called a continuous peripheral nerve block, which takes a more targeted approach by switching off only the pain signals coming from the injured limb, leaving patients' vital signs and cortical functions unimpaired.

The applicability to civilian anesthesia was obvious. In my hospital, when someone gets a knee replaced, the surgeon usually blindly injects a large amount of local anesthetic in the general vicinity of the femoral nerve and we dope them up with morphine. Patients are in the hospital for three days largely for pain control issues, all the while at risk for nausea, vomiting, respiratory depression, etc.

I took a second look at regional anesthesia and decided to use it in my practice again. This week two elderly ladies had total shoulder replacements after having interscalene blocks. They were pain free for the rest of that day. Six of my patients had knee replacements after femoral and sciatic blocks. They had no pain until the next morning.

With catheter techniques, these pain-free intervals will be measured in days instead of hours. The surgeons are giving us the time to do these techniques because they are hearing about how good they are for patients at their own national meetings. My colleagues who 'didn't do blocks' have learned to do simple femoral nerve blocks and want to learn others.

It was a good week for me because I love seeing patients do well. It was a good week for my patients (whether they knew it or not) because they trusted me enough to let me poke them with a needle once or twice to make their recovery that much easier. By next year I hope to be placing catheters and doing infusions. Thanks, Trip Buckenmaier.

New Prostate Cancer Test Show Promise

terrywfrazier@gmail.com — Mon, 30 Apr 2007 15:40:43 GMT

A little over a year ago I lost a long-time friend and mentor to prostate cancer. He was a relatively young, healthy 60 years old. He was diagnosed in August of last year. He died in January. By the time he died the cancer had spread to his lungs and his brain. His loss will be felt for a long, long time.

The statistics on prostate cancer are discouraging - it's the most common malignancy among American men. The treatments are barbaric, and our ability to diagnose early or with any specificity is poor, at best. But there is good news on the horizon.

As reported at MedicineNet, a new protein, called prostate cancer antigen-2 (EPCA-2), looks like it's going to provide a far more accurate marker for cancer cells than the common PSA test:

"We've been able to show that blood levels of it are low in normal individuals and high in prostate cancer, and that it distinguishes between cancers that are confined to the prostate and those that have spread outside the gland," explained study lead researcher Dr. Robert H. Getzenberg, professor of urology and director of research at Johns Hopkins University's James Buchanan Brady Urological Institute, in Baltimore.
His team published its findings in the May issue of Urology.
[...]
Spotting especially life-threatening prostate tumors is "the holy grail" of diagnosis, he said. Current PSA testing cannot distinguish between cancers that will grow so slowly that they pose no danger to life and those that require quick action. The hope is that the ECPA-2 test will identify men whose slow-growing cancers make them candidates for "watchful waiting" rather than immediate surgery or other treatment.

Speaking of curing cancer, if you want to donate to one of the world's most efficient charities (by efficient I mean in excess of $.90 of every dollar goes directly to research) Seth has his Pan-Mass Challenge page up. All proceeds go to the Jimmy Fund at the Dana-Farber Cancer Institute.

I Stye

terrywfrazier@gmail.com — Sat, 28 Apr 2007 16:59:39 GMT

A couple of weeks ago I was on a flight from STL to ATL and my left eye was really bothering me - felt like I had something in my eye the whole trip, but I couldn't find it. When we landed I went to the restroom and managed to see that I had what I can only describe as an in-grown eyelash. It was sort of curled back in on itself and part of it was caught under the eyelid causing irritation.

So I managed to get ahold of it and pull it out. Actually, it pretty much fell out when I touched it. And all was right with the world. Until yesterday. My eye got sore yesterday morning. By afternoon I had developed a whopping stye in exactly the same place as that in-grown eyelash. Boy, does that hurt. According to AllAboutVision the best treatment is mostly doing nothing - maybe use a little ointment or eyedrops to increase comfort. I have antibiotic opthalmic ointments and homeopathic eyedrops. Guess that's all I can do for it at the moment.

It's a beautiful day for a motorcycle ride, but I'm not sure I want to ride with only one good eye...

Something Seriously New In Printing - Bone Grafts

terrywfrazier@gmail.com — Fri, 27 Apr 2007 02:11:45 GMT

Recent article in the Daily Mail reports on new use of an inkjet-style printer being used to fashion accurate, biodegradable bone grafts for cosmetic surgery and other uses. Fascinating...

The artificial bones created from an inkjet
By ELEANOR MAYNE
14th April 2007

Scientists are creating artificial bones using a modified version of an inkjet printer.

The technology creates perfect replicas of bones that have been damaged and these can then be inserted in the body to help it to heal. The process will revolutionise bone graft surgery, which currently relies on either bits of bone taken from other parts of the body or ceramic-like substitutes.

[...]

Found via FUTUREdition from The Arlington Institute.

A Clarification on Zounds Sales Strategy and Some Industry Statistics

terrywfrazier@gmail.com — Mon, 09 Apr 2007 21:44:14 GMT

A few weeks back I was in the office on Saturday when my phone rang. On the other end was a fellow named Jay Turner, VP of Marketing for Zounds. Like any good marketing VP, Jay had been following web traffic on Zounds and came across my blog entries. As I said previously, I have no direct relationship with the company and no one there knew who I was. Even though I have a small investment, it is as part of a limited partnership and my name appears nowhere in the Zounds' records. So Jay had been looking around my blog trying to figure out who I was and why I was interested.

We had a nice conversation and Jay offered some statistics to clarify points raised in the earlier discussion. What follows are quotes from a follow-up e-mail Jay sent me. I have not independently verified these numbers but I have no reason to doubt them. Zounds did extensive market research before launch and has an advisory board that consists of medical professionals from both the ENT and audiologist fields. Further, 2006 sales statistics published in The Hearing Review show 2.37 million hearing aids sold in the US, so Jay's number of 7%=150,000 is conservative.

Per our conversation, industry research indicates 7% of hearing aids in the US (150,000 units annually) are sold through Ear, Nose, and Throat (ENT) Physicians that employ Audiologists. They buy high-end hearing aids for $1250 wholesale from the Big 6 manufacturers and mark them up to $2500 to $4000 per aid, or 2X to 3X. This same wholesale/retail pricing is used in the independent Audiologist/Hearing Instrument Specialist (HIS) channel.

Zounds provides excellent patient care through licensed Audiologist/Hearing Instrument Specialists, the best technology, and affordable prices to fixed income seniors through Primary Care Physicians (PCPs) and ENTs. Zounds sells the product and diagnostic/fitting service at wholesale (no referral fee, no Medicare/Medicaid reiumbursement, no Stark law conflicts, etc) and the PCP/ENT marks them up to MSRP $999 per aid, making far less, but for many still appealing, mark-up than the Big 6/ENT/Audiologist/HIS business model. There is nothing illegal or unethical about Zounds distribution strategy. Yes, Zounds technology, distribution, price point, and consumer marketing will be disruptive. Unfortunately, there is a lot of misinformation and emotional reaction to Zounds' business model. Overall, Zounds is trying to provide a better product, service, and price to the millions of people who suffer from hearing loss.

So, my hypothetical assertion of paying a referral fee is misleading. Zounds sells to physicians just as all other major hearing aid suppliers.

Another point Jay made in our conversation is that 10%-15% of high-end hearing aids are returned. This is not far off the number quoted by Tom Shearman (5%-10%) for all hearing aids. I would expect return rates for $2,000-$4,000 items to be somewhat higher.

And so the experiment continues. I remain a believer in the Zounds technology and approach, but the market will decide if it's ultimately the right approach. The fact that there is a great deal of emotion and misinformation regarding both the company and the product supports my belief that this is a fundamental disruption for an industry that is ripe for change.

Zounds Hearing

terrywfrazier@gmail.com — Mon, 12 Mar 2007 01:28:57 GMT

My recent post on Zounds Hearing has drawn an active comment thread, including opinions from someone in the hearing aid business. Specifically, there has been a lot of discussion of Zounds' intent to sell their product via family physicians, and whether or not this constitutes a conflict of interest or otherwise makes things worse for consumers. It's good to have a participant who appears to know the industry. If you've got an interest, for whatever reason, you might want to take a look.

Disclaimer: I don't speak for Zounds. I have no direct relationship with the company.