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Showing posts from 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 go…

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 w…

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 patien…

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…

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 a…

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, u…

Moxifloxacin for MRSA (methicillin resistant Staph aureus): Why is this not standard of care?

Moxifloxacin and MRSA. Why is this interesting?

Moxifloxacin
The drug company Bayer applied for a patent on yet another drug in the flouroquinolone category of antibiotics in 1989 and received approval by the FDA (Food and Drug Administration) in 1999 for Avelox, the brand name they gave to moxifloxacin. A Japanese company had discovered in the 1970's that adding a flourine to relatively ineffective antibiotics in the quinolone family, such as nalidixic acid, made them dramatically more active, thus creating flouroquinolones. That discovery led to the development of norfloxacin, then ciprofloxacin and levofloxacin which have become mainstays of antibiotic therapy. Ciprofloxacin is extremely useful for treating urinary infections and a variety of other serious infections including anthrax and traveler's diarrhea. Levofloxacin has become one of our drugs of choice for treating pneumonia and is especially useful because it achieves the same levels when given by mouth as it does b…

Emergency room doctors can safely use bedside ultrasound to diagnose kidney stones, saving billions of dollars and preventing some radiation induced cancers

I have been following the progress of bedside ultrasound (using ultrasound as a diagnostic tool during physical exam of patients) as it gets a foothold in standard medical practice. It has been part of my practice for almost 3 years now, during which time I have been repeatedly amazed by how helpful it is for guiding my clinical decisions. There is good research showing how useful it is for all sorts of applications, from heart problems to intestinal obstruction, but it is still slow to catch on.

An article came out just recently in the New England Journal of Medicine, which has a large circulation and should make a bit of a splash. This multi-center study looked at the option of having patients (excluding the very obese, pregnant and critically ill) with abdominal and flank pain suspected of having kidney stones evaluated first by emergency physicians with ultrasound of the kidneys and bladder before considering getting a CT scan. Normally a patient with suspected kidney stones (cra…

American College of Physicians blows this one: Pri-med "free" education on safe opiate prescribing, REMS and drug companies

I am mostly a pretty big fan of the American College of Physicians (ACP), the society that (usually) represents me as an internal medicine physician. They present meetings and conferences to spread new and relevant information and they promote gifted and hard working physicians and medical teachers. They are a force for organization in our profession which often fails to pull together and sometimes resembles a group of agitated hedgehogs. Some of the educational offerings that they produce are ground breaking, encouraging us to practice medicine that is more effective and patient centered. I do pay $525 yearly to maintain my membership, but that doesn't seem unfair.

So that is why I opened the slick tri-fold large format postcard that I got in the mail today rather than recycling it immediately. It said, "Practice safe opioid prescribing with ACP's resources." Over-prescribing opiate painkillers such as morphine, oxycodone and hydrocodone is a huge problem in the US…

The "nocebo effect", statins and Dr. Ben Goldacre

I just recently became aware of a study that came out in March of this year which concluded that statins, drugs like lipitor (atorvastatin) and zocor (simvastatin), which people take, increasingly, to lower their cholesterol and their risk of heart disease, have NO SIDE EFFECTS. Here is a paper which explains the study. It is not possible to link to the actual study in the European Journal of Preventive Cardiology because they want me to pay for it.

The paper says that, when comparing patients who took statins to ones who took an inactive pill, the side effects of both were about the same. That is called the "nocebo effect". Many people have heard about the "placebo effect" in which a sham treatment or sugar pill has a beneficial effect due, we think, to the fact that the subjects who receive it think it will work. Placebo, in Latin, means "I will please" and nocebo means "I will harm." So the researchers who wrote the paper about statins, afte…

Hand off or second opinion--how can we make transitions be a good thing?

Healthcare is actually a 24 hour a day 7 day a week job. People get sick even when we physicians are supposed to be sleeping or eating dinner or showering or brushing our teeth. Having care available all the time often saves lives and usually reduces suffering. In the US, we have that pretty well worked out: everyone with a doctor has an after hours number to call and if that fails or the problem is too big, there is always an emergency room or at least an ambulance or fire truck to whisk one away to where help is waiting.

One of the problems with our after hours options is that a person is rarely seen by a doctor who knows them and is familiar with their medical history. It would be ideal for all of us to have rapid access to the doctor (or nurse practitioner or physician's assistant) who has been with us for years and who knows what works, what doesn't and who we can relate to and trust. Unfortunately that person has to sleep and eat dinner and sometimes even go on vacation…

Population Health: what might it look like?

Blue skies...
It is a beautiful day here in this little college town. The sun is shining and at 11 AM it is about 78 degrees with a barely perceptible breeze. People are out walking on Main Street and riding their bikes. The mountain nearby calls: I can go for a hike today with my dog and still be within 20 minutes or so of the hospital to respond to calls.

A mostly empty hospital
There are two patients on the hospitalist service in this fine critical access hospital. That is a tiny workload for my profession--hospitalists, who take care of patients in the hospital who have no primary care physician or whose doctor doesn't manage their care while they are inpatients, usually don't complain unless they are managing over 18 patients in a day. I am often quite busy, but not today. One of my two patients is going home later this morning. She is bright and cheerful, with progressive Alzheimer's disease and chronic lung disease from a long gone habit of smoking 3 packs of cigaret…