Thursday, May 22, 2008

Appy Dogma

(Tis better to operate on a patient who doesn't need it than to not operate on a patient who needed it!) Some people are able to make decisions, others want somebody else to make the choice. Many times it is the pain in the RLQ that seperates one group from the other. I often think that you can teach anyone how to do an operation. In fact, the operation is the easy part. The hard part is knowing when to operate. In the classic trip to the operating room to rule out appendicitis, a pretty good average was to be right 90% of the time. The main idea is that you would rather go in and find out that it was a swollen lymph node or something else rather than miss the peritonitis of a missed appy. In this world where 2/3 of the attorneys on this planet are in the U.S., I wonder how long it will be before any negative appy is a lawsuit.

Bikini Statistics

(What they hide is ofter more interesting than what they expose) Growing up an trained in the hard sciences, statistics and scientific theory were drilled into my head. As a result, my head spins when I look at social science studies. I looked at a study of medcial malpractice coverage and my head almost exploded. In looking at a research study, we always first look at the abstract. There at the bottom will be a concise sentance that states their findings. I then look at the actual conclusion of the paper. You might be amazed to see how many times these two dont agree. The next step is to look at the methodology. If I want to compare two medications, I find a large cohort (group) of patients that are as close alike as possible. I then make sure that I isolate the group from other variables that might affect the results. I then find a way to quantify results that are empiric and this easily measured. When all this is done, we statistically look to see if there is a significant difference between the groups. When all that is done, all I can really say is whether of not there was a difference between the groups.

In the social papers. There is no isolation of variables, there are only trends. Conclusions are made from inferences that are not supported by the data. Here is a good example. "In a study of childrens accidents involving tricycles, the rate has decreased over the last few years. We therefore conclude that children are better at riding tricycles". What is not said is that few tricycles are made and being ridden and that they are now so small that when you fall you dont get hurt. Social science is based on Bikini statistics. Hard science tries to use "thong statistics". it tries to reveal all, and most of the time it reveals stuff that isn't necessary that good looking!

TIH=prob GS

(The greater the time in the hospital, the higher the probablility of getting sick). Patients often wonder why we try to get them out of the hospital so fast after surgical procedures. I would love to say something trite like it is the government of the insurance companies but in truth, it is so they don't get something nasty.

That goes for us as well. I am trying to invent a mupirocin shower additive and use that gelled alcohol sanitizer so much that I smeel like vodka. It is hard not to run into the resistant bugs. People are surviving horrible things that a few years ago would have been fatal. As the hospitals are full of sicker and sicker patients we have meaner and meaner bacteria.

The good news is that after we manage to save someone from deaths door but has to be on long term TPN and dialysis because their gut and kidneys haven't come back, the government wont pay for the life saving antibiotics. This is because the catheter is infected even though any catheter placed in the body will become infected eventually.

This just proves one of the major principles in medicine: No good deed goes unpunished!

Wednesday, May 21, 2008

It is easier to order a test that it is to talk to a patient!

(Medical/legal standard of care) In medical school I was taught that if a pateint can talk, 90% of the time they will be able to tell you what is wrong with them. The problem is that this is not true in the medical/legal sense. I hate that so many unnecessary tests are ordered as part of the CYA mentality that exists in medicine, but it has become so pervasive that know ordering the defensive tests are preferable to actually examining and talking to the pateint. A great example of this is the pateint in the ER with a headache. You don't know if it is a bad headache and they just didn't want to go to a walk in clinic where they may have to pay or if it is a horrible migrane. You see headache on the triage form and go straight to ordering a CT. There is no stopping and asking about when it started or how it progressed. The diagnosis is simple, 99% of the time you can get it right by talking and examining the patient. If you miss the asymptomatic glioma though, you get sued so off the pateint goes to CT. You then make sure that there is follow up for the pateint after their negative ct just in case they get something years down the road and try to sue you.

This is the new "Medical/legal Standard" that is taught to our residents and medical students. The actual standard of medical care doesn't matter.

Oh, what got me going on this was seeing 11 head cts in the ER while doing a consult. the ER attending was explaining to the residents that it takes 5 seconds to order a ct and 4 years to make it though a frivoulous lawsuit.

Hemophiliacs are accident prone!

In all the great medical research being funded by the NIH, I would love to truly determine if there is an inverse relationship between clotting time and clumsiness. We had a hemophiliac come in with hemearthrosis of the knee walk right into the wrong side of an automatic door and have to be readmitted for epistaxis. Anyway, when I look at all the major medical trials being conducted, the vast majority are outside of the US. The vast majority are privately funded trials but even those that are funded by the NIH are outside of the country. I spoke to one of our local medical research firms and asked them why. Their answer was they would be nuts to do it in the US and be exposed to all the liabilty. I think it is sad when even our governements attempts to advance medical care recognizes that it is better legally to get it out of the country. The good news is that we can call 1-BAD-Medicine toll free!

Ted Kennedy theory

(Thinking you will cross that bridge when you get to it.) I can't help but wonder if Sen Kennedy was in Canada, how long would it take to diagnose and treat his brain tumor? In our community we see Canadians regularly who have traveled because of the lack of timely medical care and often they have pretty serious stuff. Stuff, that if you wait gets worse. I was also supprised that unlike the rest of us, when he had a seizure which is a relatively common thing, he was med-evac'ed by helicopter. Heck, I can't even get a cab for my patients when they have a seizure. I guess health policy is different when you are the one sick.

Tuesday, May 13, 2008

Katrina Syndrome

Boy, I just have to vent. I had one of those calls that reminded me so much of Hurricaine Katrina. We had several patients come into the ER with police escort. They had been displaced by the communities recent break up of a prescription/illeagal drug ring and as a result were breaking into every house and pharmacy they could to get their fix. It was so much like the wonderful folks we saw in the Superdome after the flood cut them off from their fix.