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Tuesday, January 13, 2015

Bedside ultrasound in the developing world: what is it good for?

In the last year and a half I've been able to go to Africa 4 times and Haiti once, for which I give thanks that the world still produces abundant fossil fuels. That much airplane travel does make me feel a bit guilty, even though I'm not actually vacationing.

Going to far away places to practice medicine has always been something I hankered after, and it turns out that knowing how to do and teach ultrasound is a good way to get invited to exotic places. I think if I could do cleft palate surgery or eye surgery or had a traveling dentistry practice I could also be useful in foreign lands, but as an internist it is more difficult to find something that I can do well in a hit and run fashion which actually benefits people. Bedside ultrasound, particularly teaching it, fits the bill.

Forgive me for repeating myself if you've already heard the story, but when I quit my regular primary care practice, I learned to do bedside ultrasound. I fell quickly in love with the ability to see inside people, sharing with patients their living anatomy, quickly making appropriate diagnoses and designing appropriate management, following patients' response to therapy. I learned how to ultrasound the heart, lungs, liver, gallbladder, kidneys, bladder, spleen, intestines, great vessels, and also how to teach other people. It's been exciting and time consuming and tons of fun, and has become an integral part of my practice as an internist and hospitalist. I've written many blogs about how ultrasound has changed my practice, but I still get the question, "what's it good for?"

What it's good for varies according to the setting. A bedside ultrasound is usually done with a machine that is small enough to carry in one hand. Mine, a General Electric Vscan, is about a pound and has a screen that is just a few inches across. It gives surprisingly good pictures, but they are nowhere as good as the big ultrasound machine in the radiology suite. If that big machine was pocket sized, I'd be like the doctor on Star Trek. Because the bedside machines are smaller and less expensive than the full size ones, their resolution is a little bit worse, so they are best for asking relatively simple questions. Also bedside ultrasound is performed by doctors who also do things other than imaging and haven't spent the extensive amount of time radiologists have in learning subtleties of reading radiological images. At my hospital in the US I can answer questions with my small ultrasound machine like, "is there fluid in the peritoneum?" or "are there gallstones?" or "is the heart squeezing OK?" or "are the kidneys/ureters blocked?" I can feel confident about whether the bladder is over-full or whether there is fluid or infection in the bases of the lungs. I can see pulmonary edema and amounts of pleural fluid that are too small to be seen on x-ray. I can follow the course of intestinal distress such as gastroenteritis or obstruction. Sometimes I can't see enough to say anything, most often if the patient is hugely fat or is plastered with bandages or stickers that I can't remove. If I need to really know what is going on inside a patient who I cannot image with a bedside ultrasound, I can order a radiological study and usually get my answer in a reasonable time period. When I can look myself, though, my treatment decisions are more fluid and timely.

In the developing world there are less x rays and CT scans available, less official ultrasounds, and having the ability to do bedside ultrasound is pretty magical. There are many ultrasound machines in these out of the way places, and what is mostly needed is training. There could be more machines, of course, and when it becomes more clear how useful the technology can be, more resources may be focused in that direction. I have ultrasounded in Tanzania and South Sudan and the island of La Gonave, off the coast of Haiti, and the procedure, quick, painless and free, was profoundly influential. Last month while I was in South Sudan there was a war on nearby, and there were freshly and not so freshly wounded soldiers, which was a new thing for me. Here are a few cases of exactly what ultrasound has been good for in the developing world:

1. Young man with a gunshot wound to the leg. Is it broken? Is there a pus collection? Ultrasound is really good for ruling out long bone fractures and finding subcutaneous fluid collections. The wound was only in the muscle and a little cleaning and bandaging did the trick. No need to transfer this one to a higher level of care.

2. Different young man was injured in the face with shrapnel. He is unable to see out of one eye. Is the retina damaged (a bad sign)? Ultrasound is quick and efficient as a tool for looking at the eye, especially if the patient is unable to open it for an exam. This guy did have a thickened and abnormal retina with evidence of blood in the posterior chamber and a metallic foreign body. He is not likely to get his sight back in that eye.

3. Little boy shot in the chest and short of breath. Is it a punctured lung? A burst blood vessel bleeding into the chest? Is the heart damaged? For this boy it was none of these things, but a contusion of the lung, which looks a bit like pneumonia on ultrasound. A chest tube would have further compromised that lung and the boy avoided this procedure. Where is the bullet? It would have been great to have an x-ray to find that out!

4. A young woman with vaginal bleeding after three months of thinking she was pregnant. Is she having a threatened miscarriage or is this just an irregular period? Ultrasound is wonderful for seeing a uterus and whether there is a baby hiding inside. We saw many of these cases. Sometimes there was a baby, sometimes not. The treatment, bedrest vs. normal activity, was very different and knowing which was indicated could profoundly impact the whole family.

5. A little baby with an enlarging lumpy area on the lip. I could just imagine all of the creepy things it could be. The ultrasound showed it to be made up of blood vessels, so it is a cavernous hemangioma, which is a common benign tumor in infancy and usually goes away or shrinks by itself, and sometimes requires medications to help it go away.

6. A young man has been getting weaker, with swollen legs and a barrel chest. Is it heart disease? Perhaps something he was born with? These might be treatable with medications. Unfortunately it was not. There was a huge tumor obstructing blood flow to the heart and lungs. Good to know, though heart wrenching.

7. An old man, failing to thrive. He has back pain. Ultrasound shows he has a large bladder tumor which is blocking his kidney. Caught this late, and in a war zone, this is not treatable. Knowing helps his family to make plans.

8. An uncharacteristically pudgy woman with recurrent abdominal pain. Is it an ulcer? Actually no, her gallbladder is full of stones and is tender to push on. Surgery will help, and this lady lived in a place where that was safe and available.

9. A young woman with pelvic pain. Is it a tubal infection? A bladder infection? It is not hard to visualize the abdomen and pelvis with ultrasound, and this person had a ruptured ectopic pregnancy with blood loss into the abdomen. She will die without surgery and she will likely do fine with it. She was rushed, appropriately, to surgery.

10. A woman with a full term pregnancy: she hasn't been feeling the baby move. Is it in trouble? Ultrasound is absolutely wonderful for looking at babies, since they float around in a big balloon of water. This woman's baby looked healthy. Good news.

11. A woman acutely short of breath, with some chest pain: is it asthma (common) or her heart? Strangely enough her heart wasn't squeezing very well and her lungs looked wet. She responded well to medications for pulmonary edema and was fine the next day. I have no idea what that was about, and can't find out further because I'm home and she is probably lost to followup.

12. Pyomyositis: people get collections of pus in their legs and sometimes arms for no obvious reason. Then they get very sick and if the pus is not drained, they die. When a leg is swollen up it's pretty hard to know where to cut to release the pus unless something like an ultrasound tells you where it is. We doctors love draining pus. The young man in question, a retired child soldier, had relief of his condition and will get well.

13. A soldier, clearly sick after being shot in the belly: Has be bullet injured a blood vessel or vascular organ? Is there a significant amount of free air to suggest a major intestinal perforation? The FAST scan (focused assessment with sonography in trauma) looks for fluid, usually blood, in the belly and can determine whether a patient needs emergency surgery, if available, to avoid bleeding to death. Lots of free air looks like air anywhere, with air artifact and multiple parallel horizontal lines. This young man had peritonitis, with thickened bowel walls, fluid filled bowel loops and small amounts of fluid between the intestinal loops. He was transferred to a higher level of care after receiving antibiotics and fluids.

Also...babies with loud heart murmurs, young men with testicular swelling, the worried well...
Ultrasound in the developing world is great!

Tuesday, December 30, 2014

Just got back from South Sudan--thoughts about tropical medicine


I just returned a few days ago from the Republic of South Sudan, where I spent about 3 weeks. Jet lag is fading, and in time I may even stop complaining about how incomprehensibly bad the Juba airport was. Overall the experience was great, though.

My intention was to spend 2 weeks with my friend Jill Seaman, a doctor who has been working in Sudan for decades, primarily fighting tuberculosis and visceral leishmaniasis by establishing  and pushing treatment protocols. Jill now helps run a community hospital in the (usually) tiny town of Old Fangak, on the Zeraf River. The hospital serves a community that usually numbers a few thousand along with anyone who can make their way there, but now Old Fangak has become a busy metropolis of over 30,000 people because of the many people who have fled their homes due to fighting. My job was to help out with patient care and teach bedside ultrasound. The other week of my three week trip is how long it takes to get to and from Old Fangak. I only got 10 days there, as it turned out, since the government has become more strict about flights to and from that area because it is a hot spot in their civil war. South Sudan is a new country, having gained its independence from Sudan in 2011. There was relative peace until last December when violence broke out in the capital between supporters of the ousted vice president and the president over policy disagreements. Since the vice president was from the second largest tribe, the Nuer, and the president was from the largest tribe, the Dinka, the disagreement became a tribal conflict in outlying regions which has been bloody and destructive. South Sudan has had lots of civil war, and this situation is more the norm than peace, which was sort of present for 2 years after independence.

My last visit to South Sudan was a year ago, right before the new civil war broke out, and my timing in leaving was close to perfect, since the whole place became hellish a week after I departed. This time the war was pretty close to Old Fangak, but its isolation, with no passable roads and only access by river, made travel there pretty safe. Still, much of the medicine this trip had to do with wounded soldiers. There was also the usual constant stream of the medically ill and occupationally injured, with their tropical ulcers, parasitic diseases, diarrhea and fevers.  Complications of starvation will set in more substantially due to disruption of farmers and cattle herders, but presently food aid from organizations such as the World Food Program is keeping this partially at bay.

When I got back, the Christmas holidays were quickly approaching. Family from far away were going to descend on our house, and I had piles of journals and notes and bills and certificates on important horizontal surfaces. While taking care of these, I found the notes I took from a brief DVD course in tropical medicine, released by the Mayo Clinic, that I took last year. I don't actually have a place to put hard copy notes where I will see them again and learn from them, other than coffee tables which would look way better without stuff all over them. So I am going to combine what I learned in South Sudan in Old Fangak with my notes as a way of remembering stuff. Here goes!

Poor nutrition, homelessness, poor sanitation and stresses underlie most of the conditions we saw. The vast majority of illness and injury we saw were preventable by clean and adequate water supplies, food and shelter security, good prenatal care, waste disposal and non-violent problem solving. There were almost no uncomplicated conditions. We saw patients in several situations. There were the inpatients, who had beds or pads on the floor of the hospital buildings and were given mosquito nets. They were usually the sickest patients, with problems that were life threatening and sometimes without easy solutions. There were patients with wounds, who were living either somewhere in the compound or in the surrounding village and would come in for dressings and sometimes minor surgical procedures. There were clinic patients who came to the morning, afternoon and evening clinics, staffed by local clinicians (nurses, clinical officers and community health workers) and sometimes by a doctor. Patient visits in clinic numbered around 200 per day. Some of these became inpatients. There were patients with conditions that required less intensive observation but which required long treatment courses, such as tuberculosis, nephrotic syndrome, Kala Azar and Brucellosis. These are exotic and rare in the US and common as dirt in Old Fangak.

Malaria is the most likely cause of high fever. It is the treatable cause which needs to be ruled out first. The test we use is a "paracheck" which is a rapid diagnostic test based on presence of malaria antigens. A drop of blood from a fingerstick is placed on a plastic stick with absorbent paper inside, a drop of fluid is added and lines appear in a few minutes indicating a diagnosis of malaria. This is similar to a urine pregnancy test and can be done in the clinic or at the bedside while the patient waits. The commonest form of malaria by far in Old Fangak is Plasmodium falciparum, the most severe and acute variety. It can present with metabolic acidosis, shock, coma, renal failure, even ARDS. In Old Fangak it can have all kinds of associated symptoms especially nausea and vomiting with diarrhea. Most cases can be treated with oral Artemisin combination therapy though cerebral malaria and other severe presentations are treated with intravenous medications. Somewhat less severe versions of malaria are caused by Plasmodium vivax, ovale, malariae and knowlesi (usually in southeast Asia) and these have different fever patterns. The Anopheles mosquito transmits malaria and is controllable with elimination of standing water (mostly impossible) and use of insecticides. Since these mosquitoes primarily bite as evening falls, use of mosquito bed nets, especially for children, drastically reduces malarial disease. Pregnant women are treated monthly during their first trimester with Fansidar (Sulfadoxine/Pyramethamine) because they are more susceptible to the disease and because it can cause miscarriage.

Visceral Leishmaniasis, also known as Kala Azar, commonly presents with prolonged fever, enlarged spleen and liver, sometimes with diffusely enlarged lymph nodes, and bone marrow involvement which can lead to anemia and low platelet and white cell counts. It often coexists with HIV infection, though not so much in Old Fangak where HIV is still relatively rare. It can be diagnosed with a rapid diagnostic test which detects rK-39 antibodies and is about 80% sensitive. If this is negative, a DAT (direct agglutination test) is performed which should detect 95% of cases. A lymph node aspirate can detect the actual organism, which is helpful when the immune response is not vigorous, like with HIV coinfection. It is about 60% sensitive, and can be used for detection of recurrence, unlike antibody and agglutination tests. Spleen aspirates, also useful in recurrence, have sensitivities as high as 95%. The lab staff is capable and confident in performing lymph node aspirates, which in the US would be a great big deal, and splenic aspirates are performed at the bedside in patients without significant bleeding risks, quickly and nearly painlessly, with vanishingly rare complications. The specimen is smeared on a slide, giemsa stained and examined for the tiny protozoans which look like an eyeball with a dot and are about the size of a platelet. The disease is usually treated with sodium stibogluconate (SSG) and paromomycin injections for about 3 weeks, which often cause nausea and vomiting an can also cause fatal heart arrhythmias and kidney problems. A less toxic but much more expensive option is liposomal amphotericin B which is given intravenously on an intermittent schedule, usually over 21 days. This is used for resistant or recurrent cases and in patients who don't tolerate the SSG/paromomycin regimen.

Back pain and tenderness, prolonged fever with weight loss, chronic arthritic joints in children, unexplained chronically enlarged lymph nodes, especially with fluid collections inside and cough with fluid around the heart or lungs is usually tuberculosis and requires prolonged residence at or near the hospital compound for directly observed treatment. Treatment of TB is effective and lifesaving and most patients comply with medication therapy which is impressive. Worries about contributing to multi-drug resistant tuberculosis slowed the development of programs to treat the disease, but at Old Fangak people are getting appropriate therapy along with nutritional support, blankets, mosquito nets and sometimes shelter and are being cured of their TB.

Nausea, vomiting and diarrhea could be anything, but is often Giardia. In many areas of Africa good sanitation has made this uncommon, but it is pretty rampant at Old Fangak. Despite aggressive latrine construction, babies and children, especially those with diarrhea, leave Giardia parasites everywhere, and though both Sudanese and Americans are clean and tidy in their own homes, the hospital compound seems to be covered with a thin layer of filth. Most floors are dirt. The floors that aren't dirt are mopped daily, but walls are not and small islands of cleanliness do not make a huge overall difference in infection control. Giardia is treated with tinidazole which tastes horrible and is slightly nauseating. It seems that, improbably, most children actually take it when it is prescribed.

Schistosomiasis is probably nearly universal, since most people swim and bathe in the river, which carries the parasite to the skin of the human host, which it penetrates to cause infection. Schistosomes are blood flukes which can affect most body systems, but schistosomiasis is usually either assymptomatic or associated with symptoms that are hard to notice, such as discomfort with urination or fatigue from chronic iron deficiency. The two types present in Africa are mansoni and haematobium. Mansoni is famous for causing portal hypertension with symptoms of liver failure, but more commonly causes chronic intestinal distress and intestinal blood loss. Haematobium is known for causing scarring and sometimes cancer in the bladder. The eggs can be identified in urine or stool, but in Old Fangak it is most often treated when patients present with classic symptoms, since most people are likely chronically infected. Reinfection is nearly impossible to prevent, though in some countries routine and repeated blanket treatment has been tried. Praziquantel, as a single dose, is usually effective in clearing the disease, and is sometimes used prophylactically for children at high risk.

Tapeworms and roundworms are surprisingly rare in our little community, but with the influx of internally displaced people that equation may be changing. These are pretty easily treated with a single dose of a pleasant tasting tablet, albendazole. They can cause intestinal distress and malnutrition and are associated with poorer school performance. I did see one case of an overwhelming infection with Strongyloides stercoralis, a roundworm, in a young woman who was chronically ill with kidney failure and vomiting who had tiny worms in her urine. Despite appropriate treatment, she died. Once this infection becomes so widespread it is hard to eradicate and usually implies an associated immune dysfunction. Malnutrition and kidney failure might have been what made her vulnerable.

Brucellosis is a disease carried by cows and dogs and transmitted to humans primarily through contact with their urine and feces. The cows, which are a common form of wealth and currency in South Sudan, are heavily infected. A vaccination program could be very effective in reducing cow morbidity (primarily abortion and infertility) as well as human disease but hasn't been tried. Ongoing civil disruption due to war gets in the way of all sorts of good ideas. Brucella causes recurrent fevers with nausea and vomiting and overall feeling miserable and can persist for years, causing chronic arthritis of the large joints and the back. Most infection is assymptomatic. It can affect the skin, with rashes, the eyes, causing inflammation and blindness, bladder, testicles and ovaries, lungs and brain. It is diagnosed in the lab with a serum agglutination test and treated with 6 weeks of doxycycline along with 2-3 weeks of gentamicin, which is usually given as a rather painful intramuscular shot. It frequently recurs.

Chronic kidney disease with nephrotic syndrome is surprisingly common and probably related to ongoing immune system activation by repeated infections of various kinds. This is treated with a slow taper of prednisone, which sometimes works. Patients usually present with facial and leg swelling along with frequent urination and fatigue. There is a fingerstick monitor of the creatinine level, something I haven't seen in the US, which is the only available way to document the status of a patient's kidney function. High blood pressure is treated appropriately which helps in recovery or at least to slow the progression of disease. Endstage kidney disease is right now a terminal diagnosis since there is no available dialysis or kidney transplant available to these people.

Late stage cancer is surprisingly common. There was a 17 year old boy with a tumor in the chest that had displaced his heart to the right chest cavity and obstructed blood flow into the heart. It was likely a mediastinal germ cell tumor, since this is not terribly uncommon in young men. It is quite sensitive to chemotherapy, even curable, but this person presented at such a late stage that he would have been lost even in the US. He had been in bed close to a year, had deep bedsores and legs which no longer would straighten. He had devoted parents and a winning personality. He died after a week in the hospital. There was a man who came in unable to swallow. This had progressed over a year, but his esophageal cancer (visible on bedside ultrasound) had now completely obstructed his swallowing and, though he would receive some intravenous hydration, there was nothing we could do for him. In the US he would likely have died, but would have had palliation with radiation therapy and a feeding tube. Esophageal cancer is common in East Africa. A woman returned to clinic after having received radiation and chemotherapy for a tonsillar cancer that turned out to be a lymphoma. With advice from doctors who were friends of Jill's, she received appropriate therapy and was free of disease when she returned. A beautiful young man had a deep and fungating wound of the right groin that was foul smelling and liked to bleed. It appeared to be a squamous cell carcinoma, but we did biopsy it and results are pending from Nairobi. He could get radiation therapy for palliation if transport could be arranged and if he is able to survive that long.

Tropical ulcers are very painful and appear usually on the lower legs after minor trauma. They are inhabited and probably caused by a collection of bacteria and can cause bone infections and even cancer if untreated. These are very common, and are treated with dressing changes, debridement and antibiotics. Presently we are using gentian violet topically which seems to speed healing. War wounds often cause extensive tissue damage and are treated with dressing changes and sometimes delayed primary closure once they are clean and healing. They can be disfiguring and painful. I tried a combination of guar gum (a component of many high tech wound dressings) with powdered antibiotics for some of the more weepy wounds. This was popular with the patients but I wasn't there for long enough to see if it improved healing. It did appear to reduce evidence of infection.

Pneumonia, especially in kids, and diarrhea with dehydration in babies accounted for a reasonable amount of sickness. Most pneumonia is treated, successfully, with amoxicillin, some with ceftriaxone, and diarrhea was treated with oral and sometimes intravenous rehydration, with treatment for the specific cause if that became at all clear, often with antimalarials or antibiotics. Runny nose with runny eyes, especially in the presence of rash was measles and often quite a severe disease in small children. Most medical missions take vaccination of children quite seriously, but most remain unprotected.

In the US I normally see complications of heart failure and vascular disease, primarily related to smoking and obesity, diabetes and its sequelae, chronic lung disease, again related to smoking and infections that are often complications of IV drug abuse. I also see the devastations of extreme old age with dementia worsened by urinary tract infections or pneumonia. None of this is common in South Sudan. In the hospital at Old Fangak the common conditions are about as diverse as I see at home, but the options for diagnosing and treating them are much more limited. For me there was quite a steep learning curve. 

Staff from the community who have little or no formal medical training do a tremendous amount of the work, including diagnosing and treating very significant and, for me, exotic diseases. This is made possible by protocols developed by generations of doctors, including ones working with Doctors Without Borders and especially Jill Seaman who has been doing this kind of thing for a really long time. When no Americans are present, Kala Azar, tuberculosis, brucella and many other diseases are treated effectively and followed appropriately by South Sudanese health workers. They could certainly use more training, but I am in awe of their skills. I saw one of them put an IV in a dehydrated baby with no difficulty which I doubt could have been done with such skill in a US hospital. With access to medical and nursing school, which they do not have, their potential would be tremendous.

Working in Old Fangak is something that doctors dream about. It is expensive to travel there and disruptive to my work schedule, and there are all kinds of diseases that are easy to pick up. There are grouchy people with AK47's wandering around looking twitchy. The medical care requires flexibility and is often incredibly frustrating when lack of resources makes it impossible to solve a problem that is so very soluble if only the situation were different. Still, the company was excellent and the patients were great and the attitudes and skills of people working there were inspiring. It was deeply fulfilling, I learned a ton and have a bunch of great stories. Also... hooray, I didn't die!

Monday, December 1, 2014

In hospital versus out of hospital heart attacks: wow, things sure cost a lot of money!

An article from the JAMA (Journal of the American Medical Association) has been gnawing at my consciousness for the last couple of weeks. Dr. Prashant Kaul and colleagues out of the University of North Carolina reviewed records from hospitals in the state of California from 2008 through 2011, looking for patients who had been hospitalized with heart attacks. Specifically, they were looking for patients with ST elevation myocardial infarction (STEMI), which are generally the most damaging and deadly of the events generally known as heart attacks, due to the amount of damage they do to the heart muscle. The authors compared patients who were already in the hospital for another reason when they had their heart attack, versus ones who were admitted specifically for heart attacks. They found that the patients who were admitted specifically for the heart attacks were generally younger and healthier, more often male, and were much more likely to survive than the ones who were hospitalized with other illnesses at the time of their STEMI. This is not terribly surprising, since people who have some other problem bad enough to put them into the hospital and then develop a heart attack on top of it are clearly at a disadvantage, even though there are cardiologists with magical potions and procedures close at hand.

What was most interesting and disturbing to me was the sheer astounding magnitude of costs associated with these groups of patients. The patients admitted for STEMI stayed an average of 4.7 days and total costs were $129,000. About 9% of them died. The patients who were already in the hospital at the time stayed an average of 13.4 days, their costs were $245,000 and a third of them died in the hospital.

I don't think we should get jaded to numbers like this. This is real money, the kind of money that can buy a house in some places or at least a very hefty down payment, can support a person for years, and the co-pays on which can destroy a family financially. As a person is racking up such a bill, there are days of inadequate food and sleep, indignities of hospital gowns and waiting for someone to come with medication or to allow one to empty bladder or bowels, if it's not already too late. And death, in 9-30% of the people thus cared for. In a hospital. This money is not buying comfort and luxury. What costs so much? I'm not entirely sure. The interventions done on people with heart attacks include bypass operations, which are costly, but happen to very few of these people. There are the "percutaneous interventions" meaning high-tech catheters passed through arteries to place stents in clogged blood vessels in the heart, which are also terribly costly, sometimes as much as $40,000 for placing a tiny metal finger trap in a partially blocked artery. More stents are placed than need to be, per many studies, but an STEMI is definitely a good reason to place a stent and doing so is often life saving.

But why? Why so much money? There is nothing absolutely expensive about any of this. A little expensive, yes, but not hundreds of thousands of dollars. But the costs add up. The equipment is getting incrementally slightly better and is priced somewhere in the ozone. But it's not about raw materials or time or any of the resources that are truly set in stone. The costs just rise to the level that we agree to pay. The many places where money hemorrhages from the system feed our vibrant healthcare economy. We pay huge amounts of money to insurance companies who disburse it to the entities that charge this much. If there were limits on costs, or even goals for cost cutting, I'm confident we could slim down our spending. But there aren't and we don't.

Heart attacks and their treatment are just a tiny piece of the picture. There are still a few good values (a needle and syringe still costs less than $1), but generally everything that has to do with healthcare is overpriced. I learned a new computerized medical record keeping system last week and talked at length to the trainer who had been instrumental in adopting it. I complained because it was clearly clunky and lacking in the subtleties that would have made it really useful. I asked about another program I had heard about which was looked at as the best. According to her, the "best" cost about half a million dollars per hospital bed to implement. A medium sized hospital might be 200 beds. So 100 million dollars. Apparently hospitals, hoping for efficiencies, have gone bankrupt after adopting this Mercedes Benz of medical records. And the other systems aren't much cheaper. How is that even possible? There are almost no fixed costs in computer software. They charge this much entirely because they can.

There are no obvious solutions to this, while we remain attached to a non-centralized third party payment system. Payment structures are changing, but slowly, and the powerful interests who make money off of this system seem to escape ideas made to dampen profits. As individuals, though, it's important to continue to notice that things cost too much, they don't have to, and it's not OK.




Wednesday, November 19, 2014

Lions and Tigers and Doctors Unionizing, Oh My! Interesting developments in the field of hospital medicine. (Fresenius buys Cogent and Sound hospitalist companies. Is that good?)

I am presently doing locum tenens shifts in a lovely community in Oregon as a hospitalist. (For people not steeped in the lingo, that means I am filling in as a hospital doctor.) I have been to this hospital before and was glad to return when they needed some help. I like this place and noticed on my first go around that patients got good care and that physicians and nurses all seemed to get along pretty well together.

When I first worked here, 2 years ago, they had just transitioned away from a national company that organized and provided hospitalist coverage. The company was expensive for the hospital and refused to work with the doctors to allow them to have reasonable work loads. Not having a reasonable work load as a doctor is not just an irritation, it is dangerous. An overworked physician is not available to respond to, or ideally avert, emergencies. Because doctors are primarily over achievers, being unable to provide good care because of being responsible for too many patients is incredibly demoralizing and often results in burnout, with its associated depression, anxiety and sometimes substance abuse. We hurry through our visits with patients because there are so many to see, missing important clues to diagnoses and ignoring social issues that are vital for providing appropriate treatment.

At this hospital, the doctors met with the administration and came up with a plan that involved getting rid of the hospitalist company, managing the staffing and billing themselves with the help of a hired coordinator. They still have days when there are too many patients to see, but they have hired enough staff that this is rare and they are free to adjust in order to maintain good patient care. This was not possible when they were employed by the national company.

Hospitals, though, often balk at the idea of managing their own hospitalist groups. This is for good reason. Hospitalists are expensive. Even though we take care of many patients, the money we bring in as revenue to the hospital does not cover our salaries. In fact, it doesn't even cover half of our salaries. Partly this is because many of the patients we see are unable to pay anything for their care. The sickest of patients often have poorly paying Medicaid or state funded insurance or have no money or insurance at all, which is partly why they are so sick, or at least strongly associated. Hospitals are willing to subsidize a hospitalist service, though, because having hospitalists attracts many of the physicians that do make a hospital money, such as surgical subspecialists. These folks need to be able to do operations and be available for emergencies requiring procedures without worrying that they will be called away by hospitalized patients who have complex medical problems outside of their area of expertise. Hospitalists are mostly internal medicine physicians who are good at managing all kinds of chronic medical problems and are in the hospital all the time, ready to take care of any patient who needs urgent help.

There is risk associated with managing a hospitalist program. Doctors sometimes get sick (god forbid) and replacements are needed, which can be difficult at the last minute. Occasionally a doctor who is hired for a position as a hospitalist, who sounded really good on paper, turns out to be pretty awful. They have a terrible temper and yell at nurses or they never do their documentation or they have bizarre practice styles. Whoever is in charge of a hospitalist group must find somebody to fill in, super quick, plus try again to find the right permanent member of the group. Running such an organization is not for the faint of heart.

Intrepid, expensive and mostly mercenary companies have arisen to fill the void. "Afraid to run a hospitalist program? We will do it for you and it will only cost millions or dollars a year!"

A California hospital where I have worked answered just such a clarion call. Their hospitalist group
had formed out of community physicians and new hires and had even involved a merger. The doctors kept track of their patients' billing information and billed them directly, and never worked particularly well together. Nobody was boss, so standards of care were a bit haphazard. They made considerably more money if they saw more patients, so even though they hated being overworked, they tended to end up with over-large patient loads. They knew exactly how much hiring doctors to fill in cost, since it came directly from their pockets, and they were loath to do it. They became burned out. The overwork and burned-outness made other physicians not want to work there. So they agreed to have a national hospitalist company take over. This is looking like a disaster, though only time will eventually tell. They will take a pay cut, and the company will expect them to continue to maintain higher than safe patient loads. Many have already quit.

Just yesterday I heard about a hospitalist group in Eugene, Oregon, which has decided to unionize because of overwork (local paper article here, with excellent commentary). Thirty six doctors at PeaceHealth hospital in Eugene and Springfield have decided to form a union, which will be part of the American Federation of Teachers. This large group also is a home to nursing unions, so the connection is not all that weird. Attempts to reduce costs associated with the hospitalists by the hospital administrators lead to unmanageable patient loads. The hospital dealt with the doctors' complaints by proposing having a national company take over the program. The doctors voted to unionize, a strategy that has helped nurses have a voice in the past, when reduction in staffing and salaries made them very unhappy.

I'm not quite sure how this will play out. The hospital can still hire an outside company to provide hospitalist services, though they will have to negotiate with the union if they want to use the local physicians who really know the patients and the system. Well paid scabs might fill the void.

I have worked for two national hospitalist organizations in the last 3 years, and although I appreciated some of their good ideas in areas like communication and education and patient safety, the workloads were mostly just awful. My very first locum tenens position was with Sound Inpatient Physicians, a large hospitalist company. After 1 day of orientation with 16 patients to see, I accelerated to the usual patient load of 19 patients who I didn't know, many of them complex, during an outbreak of Norovirus, so I had to gown up for about a third of them, and got 2 new admissions. I rarely finished my 12 hour shifts in less than 14 hours, and barely had time to go to the bathroom. A well deserved high level of anxiety plagued me most moments of each day, as I rushed from acutely ill patient to acutely ill patient while receiving multiple pages on my beeper. The other company, Cogent, employed me as a locum tenens physician in a PeaceHealth facility in Washington. The doctors were great, though not happy. At all. The administrators were ninjas of awesome skills, but the workload was ridiculous. Just a few days ago the large German healthcare company Fresenius, which had bought a majority share of Sound Inpatient Physicians earlier this year, purchased Cogent as well. I would like to believe that good qualities of German healthcare will now perfuse these two companies, but I seriously doubt it. Fresenius also owns a large amount of American kidney dialysis capabilities, and hopes to combine their dialysis arm with their hospitalist business to better coordinate care. I will not simply assume that this will raise prices and result in overuse of their technology, since some good might come of it.  Fresenius did lose my vote of confidence, though, when they threatened to sue a researcher who wrote a scientific article that showed that a product they sell, hydroxyethyl starch, causes more death and kidney failure when used to resuscitate critically ill patients.

All this said, I should really admit to the fact that practicing as a hospitalist is a pretty good job. The patients are always interesting and they pay us well. There is no pay, though, that is adequate to make it OK to take care of too many patients at one time when doing so puts them at risk. Allowing doctors to have weighty input on work load, be it as part of a union or by being part of a well functioning independent hospitalist group, is vital to having good patient care and sustainable job satisfaction.

Wednesday, October 29, 2014

How does a non-cardiologist learn echocardiography? What's the deal with all of these ads for "123Sonography"?

Last Spring I got a junk e-mail offering a free "Echo survival course" from the University of Vienna, in Austria. I just had to go to a website, enter my e-mail, and I would get 4 free modules on basic echocardiography. Cool, I thought. Free knowledge! I've wanted to know the deepest secrets of echocardiography since I was a wee medical student a quarter of a century ago.

But why, one might ask, would it be relevant for me to know echocardiography? I'm not a cardiologist after all. Cardiologists are the people who read most of the heart ultrasounds, or echocardiograms, that are performed in the US. The usual routine is that someone like me, a general internist, or a family practitioner, orders an echocardiogram for a patient with a suspected heart problem. An ultrasonographer, a non-physician with expertise in performing ultrasounds of the heart, obtains images of the heart from various views, saves representative images, performs calculations of movements and sizes of structures and sends the whole file to a cardiologist who interprets the data. The cardiologist then produces a document with various abstruse and arcane abbreviations and corresponding values which also, thankfully, contains a summary paragraph which says if the heart looked normal or not. This whole process can take up to a week from start to finish. The patient or the patient's insurance company will be charged one or two thousand dollars and at the return visit the patient's physician will likely say something like, "it looked pretty good" or "one of the valves is a little leaky so I'm going to have you see the cardiologist" or "it wasn't too bad for someone your age."

I have been doing a rather quicker and more focused version of the echocardiogram as a bedside procedure for the last 3 years which frequently serves my purpose much better than the scenario I just described. It is possible to learn the basics of cardiac ultrasound through continuing medical education classes taught by emergency physicians, who have used bedside ultrasound for decades to more capably triage patients. Ultrasound machines have gotten smaller, more ubiquitous in hospitals (often you can find one nearby if you need it) and even affordable to own and carry around. Mine fits in a lab coat pocket and gets pretty good images from which I can make more informed decisions regarding my patients' diseases and appropriate treatment. It doesn't replace the full scale echocardiogram, except in cases where the details are unnecessary. I have done thousands of focused echocardiograms, reviewed them with experts when that was appropriate, compared the results to full scale echocardiograms when those were done, and know much more about the normal and abnormal heart than I did during the first two decades of my internal medicine practice when I relied primarily on my stethoscope. My bedside echocardiograms tell me if the heart is weak, and how weak, if there is fluid around the heart, whether there is evidence of problems with the blood vessels in the lungs and if there is damage from long term high blood pressure. I can identify the moment of death quite accurately when attending the dying and can see if an acute heart attack is causing a patient's chest pain or breathing problems. I can avoid giving medications that the patient's heart will not tolerate.

When it comes down to it, though, a good cardiologist is better at interpreting an echocardiogram than I am. I am not qualified to take the images and arcane numbers produced by an echo technician and produce a succinct but exhaustive summary. I am an internist, which is a fine and noble job, but not a cardiologist. So, since I look at hearts at the bedside all the time with a small ultrasound, I would like to know more about the fine points of echocardiography.

I have looked around for years for a good way to learn echocardiography and found that, for someone already in medical practice, it is pretty tricky to get echocardiography training. There used to be a guy, an echo technician by training, who ran courses for internists and anesthesiologists in performing and reading echocardiograms, but he got old and pretty much stopped doing it. He also really did not approve of bedside ultrasound. His courses were expensive and weeks long. After completing a course, to be credentialed to read echocardiograms required shadowing a cardiologist for a period of time and then reading echocardiograms which were over-read by a cardiologist. It would have been much easier if I had only known I would need this when I was still in training.

So it was very exciting when the offer of a free echocardiography course came to me in my e-mail. I followed the links and found that the 4 module free course was well taught and informative. I was still wary, but plunked down $757 for a full "master class" in echocardiography which was self paced and gave me 30 hours of training. I had 6 months to use the resource material. It was really pretty good. The faculty is all from the University of Vienna, in Austria, which is a real place, not like University of Phoenix or something. The faculty are real cardiologists, clearly interested in their material and their English is just fine, though spoken with Austrian accents. Both image acquisition and interpretation skills are taught and there is an emphasis on understanding not just the echocardiogram but the physiology of the heart and the underlying disease processes. There were 20 modules, with quizzes following each. The quizzes weren't particularly well written, but were detailed enough that it was necessary to really pay attention. There were exotic European spelling and grammar errors which did not distract from the material. I completed the course, got a certificate of completion and I feel pretty certain that I still am not qualified to read a full scale echocardiogram. I do, however, understand quite a few more subtleties than I did, and will continue to do bedside focused echocardiography with renewed appreciation.

I think this course is much more aimed at training physicians in resource poor settings where nearly all doctors are generalists, and having a physician who is able to read an echocardiogram, even without knowing the finer points, is life saving and really all that is available. Doctors in these situations will use a course like this to go from knowing close to nothing to being able to capably diagnose the majority of cardiac conditions, to their patients' great benefit. This was truly an educational niche that needed filling. The teachers also do in-person few-day courses in various locations, which I would love to attend at some point, not least of all to see what the student body is like. If they are fantastically successful (and I kind of think they are) perhaps there will be competition, and possibly even accessible education in the US. It has seemed like the lack of educational opportunities acted to protect a piece of lucrative turf claimed by cardiologists. The US is not primarily made up of urban areas, though, and large portions of our geography, like where I practice, for instance, are not served by cardiology clinics. I am glad a resource like this exists, even though online training in something that is hands-on cannot expect to fully cover the educational needs of practitioners.

Tuesday, October 21, 2014

Ebola!!! What about everything else? Influenza for instance.

Ebola virus has grabbed headlines since the epidemic started in West Africa nearly a year ago. The death toll is estimated at 4500 people, and the epidemic continues to spread. One person infected in Liberia returned to Texas with the disease and died, infecting maybe 2 healthcare workers.

Ebola is a nasty virus, surely, with a case fatality rate of 80%. Overall health and nutrition as well as living conditions have an effect on how sick a person gets with it. We have no good treatments, though antibodies and other biologically based treatments are being used and may be rapidly developed to combat the disease.

But have we forgotten influenza? Influenza is a nasty virus, with a few marginally helpful treatments. Its symptoms are fever, headache, cough, sore throat, runny nose, sometimes also heart failure, respiratory failure and brain dysfunction. It will likely kill tens of thousands of Americans this season, mostly the very old and very young, but also perfectly healthy people.

How about other globally relevant diseases? One and a half million people in the world die of AIDS yearly, the same number of tuberculosis, about 700,000 of malaria and more than the total of all three of these of malnutrition.

So we can't do very much about Ebola at this point, other than perhaps support the overseas programs that are trying to help the affected West African countries--Liberia, Sierra Leone, and Guinea. These
will probably have a more significant second wave of misery due to the economic devastation brought about by the epidemic. In the US Ebola is not likely to be an issue of significance. Perhaps learning to don and doff HAZMAT suits will benefit us in some as yet unknown way.  I am open to scorn and censure if I am wrong.

What should we do about influenza, since that routinely kills many thousands of us? Should we all get flu shots? I am not entirely convinced. I get them every year and induce my loved ones to do the same. The flu is utterly nasty, even if it doesn't kill you. It comes on like a freight train, with upper respiratory symptoms and intense misery. It hurts to move your eyes. You can barely think and you certainly can't work, at least after the first day when you go in and infect everyone else. The cough lasts weeks. You are infectious for at least a week. Old folks go from flu to pneumonia and sometimes die. Anything that will lessen my chance of getting it is welcome. Still, wholesale vaccination programs of healthy people do not statistically decrease hospitalizations or work loss, and 70 people must be vaccinated to avoid one case of influenza. This is per a large Cochrane Collaboration evaluation of many well designed studies.

As we enter influenza season probably the most important thing to do to avoid the disease is not to spread it. People with classic flu symptoms should not go to work or school, should not fly or travel in any public conveyance, and if they try, they should be sent home. Will we actually heed this advice? No, at least we haven't so far.

What about malaria and AIDS and tuberculosis and hunger? There are lots of great ideas out there, from newer medications to public health campaigns, promoting peace, helping women farmers, digging wells, curbing environmental abuses, that sort of thing. Committed and creative people are working all the time. We just aren't hearing much about them since apparently the most pressing global health issue right now is Ebola.

Thursday, October 16, 2014

Why do drugs cost so much? Confused and fuming about the unfairness of it all...

Drug prices are a difficult issue to write about because real data about the workings of pharmaceutical companies is very difficult to uncover. Still, last week I came face to face with something that seemed extremely not right and so I feel I should at least make some comment. It started when I prescribed a patient sumatriptan for her recently more frequent migraines. Her cost exceeded my wildest expectations.

Sumatriptan is a nearly magical medicine which was FDA approved in 1991 for treatment of acute migraines.* It is similar to the neurotransmitter serotonin and reduces inflammation of arteries in the brain which is associated with migraine headaches. It does other things as well, and may have a much more complex mechanism of action. Although it has some side effects, it works well for most people, can be given as an injection, pill or nasal spray and doesn't cause drowsiness, constipation or nausea like many other pain medications can. When sumatriptan was first released, under the brand name Imitrex, it was astoundingly expensive. I can't remember what it cost, but it was a bundle. People were willing to pay because it often saved them a trip to the emergency room or many hours of misery. Global sales of this drug top 1 billion dollars yearly. It has been approved as a generic since 2008.

Back to the patient. I prescribed thirty 50mg pills of sumatriptan, generic, via a national pharmacy chain, hoping that she would be able to treat her migraine at home, have leftover medications for future migraines and avoid a trip to the emergency department. The pharmacy told her it didn't take her insurance and that the prescription would cost her $550. She didn't have $550. I called the pharmacy, told them that I meant generic, not brand name, and they told me that they understood that and that the cost was $550. I called an independent pharmacist who I know well and asked if this drug was still ridiculously expensive or if there might have been some mistake. She said that her cost for 9 pills (they come in 9 packs for no particular reason) was $6.50. At her pharmacy she would charge an uninsured patient cost plus a dispensing fee. That would be about $30 for 30 pills. I got online to see how Canada charges for this drug, and"Canada Drugs" which sells medications at Canadian-ish prices to people in the US charges about $40 for nine 50 mg pills. A physician blogger, Leslie Ramirez MD, who is particularly interested in pharmaceutical costs reported that Costco, an American wholesale warehouse club had drug prices that were at pharmacy cost plus 14% dispensing fee. Costco's price for nine 50 mg sumatriptan pills was about $14. Although Costco requires a membership for most of their merchandise, anyone with a prescription can buy medications there. (Leslie Ramirez's website on cost comparison of drugs in the Chicago area disappeared around 2011 after this article was written about it in Forbes Magazine.)

So this person, my patient, with a raging headache, left her pharmacy empty handed because she was unable to afford a medication which had been marked up over $500 above cost, a medication which has been available as a generic for over half a decade.

I asked my pharmacist friend what this was all about, and she said that it had to do with "Average Wholesale Price" which is a number created by pharmaceutical people and distributors, originally intended to represent the actual cost of medications, allowing the price paid by insurance companies to be standardized. Since large pharmacies base their prices on AWP, that $550 for 30 sumatriptan tablets was probably pretty well set among retail pharmacies. Hiking up the AWP has various benefits to the many players in the pharmaceutical industry. Pharmacies can benefit because their costs are usually much lower than the published price (on average 14% lower, but clearly much much lower in some cases) meaning they make a handsome profit on some generic medications, wholesalers benefit since pharmacies want to buy drugs that they can sell at a substantial profit and pharmaceutical companies that produce brand name products benefit if generic drugs are kept artificially more expensive, since patients will often spring for the brand name original or be willing to pay high prices for new nearly identical brand name drugs.

It sounds like drugs are more expensive than they should be because there is collusion to overcharge for them. But it is not all based on Average Wholesale Price rigging. The cost of generic drugs to pharmacies has also gone up drastically. This article in the online version of the Wall Street Journal reports on rising costs of generic drugs, sometimes as much as 8000 percent (in the case of the antibiotic doxycycline), at least some of which was associated with rising costs to pharmacies. I wasn't able to find the actual data, but apparently lawmakers are "probing staggering price hikes" and sending letters of inquiry to the drug manufacturers asking why prices were raised, how much money they are making off of the affected drugs, who is responsible for price hikes and how costs for these medications compare overseas. The letter I linked was sent earlier this month and I don't see any information yet about a response.

Price hikes would seem to negatively affect patients, of course, but also insurance companies which pay at least some of these costs. In my review of the Affordable Care Act I haven't come across any provision that controls how much drug companies charge for their products. Old laws against price fixing do seem to apply to this sort of thing, but there is nothing new that says that Mylan, for instance, can't make a drug that cost $11 a bottle one month increase in cost to $400 a bottle a few months later. The insurance industry, though, is powerful enough that I would think they would balk at these price hikes. Medicare itself is not allowed to negotiate prices with drug companies but private insurance companies can. I'm not quite seeing what dynamic is at work here to keep them from refusing to pay for overpriced drugs.

Another thing I don't quite understand is why, when Costco charges cost plus 14% for medications consumers and insurance companies don't avail themselves of this option. I do love my corner drugstore, and realize that they survive partly by selling inexpensive drugs to insured patients for inflated prices, but I wonder why this continues to happen. It is truly valuable to have an independent pharmacist dispense medications and maintain a relationship with physician prescribers and patients, as happens in locally owned pharmacies, but we should find some way of paying for this service that is not arbitrary and subject to whimsical fluctuations.

The explanation that makes the most sense regarding drug prices is that the producers and purveyors of pharmaceuticals will charge as much for their wares as anyone will pay. Doctors cannot help because they are not aware, at the time of a patient encounter, what of their many drug options for a given condition is the best value. Unless lawmakers have the stomach to regulate the profits of big pharmaceutical companies, their most powerful lobbying entity, or enact legislation to allow market forces to reduce drug costs, prices of medications will continue to be subject to staggering increases.

*"Nearly magical " is a bit of an overstatement. It does work pretty well compared to other pain relievers, but only about a third of patients taking it have relief of their headache in an hour, and only 1 in five is headache free 24 hours later.