Minute Clinics

I saw a story on the ABC Nightly News this week that really was rather one sided (I haven't been able to find the link yet). The story dealt with so called rapid health care available in mass merchandisers like chain pharmacies, and big block retailers. Now with 40 million Americans with no insurance, anything that gets more affordable health care to folks should be a good thing, but the story was still kind of slanted. Here are my thoughts:

-The piece did not mention once that the care is often delivered by ancillary providers like nurse practitioners. This is not necessarily inferior, but they should realize there is no doctor at the clinic.

-While the costs are less, these places often don't accept insurance. For those that have health insurance, then this will end up being an out of pocket expense.

-If the clinic is in a pharmacy, there may be financial pressure exerted to prescribe more expensive drugs for treatment of a particular condition. Think about it, would a pharmacy clinic really encourage its practioner to utilize less expensive generic drugs?

-The story made no mention that this is probably adequate care for younger, healthier adults with simpler, acute health care needs. For a 20 year old women with a simple bladder infection, this can be a cost effective and convenient way to get an antibiotic. However, older Americans, with chronic health conditions deserve continuity of care, and better followup than these clinics can provide. Our diabetics, cardiac patients and COPDers need careful long term care to ensure their long term disease free survival. With our aging demographic, we have far more of these that need health care.

With the above points in mind, this makes the idea of a "minute clinic" just not right for the majority of adults that need health care.

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On Digital Radiography

One of the hospitals I work at is converting their radiology department to all digital. They promise to have better organized films, and a faster turn around time. This is going to be supported by over twenty computer reading stations, strategically placed around the hospital floors to be be able to access these films.

The allure is great. To be able to view films on the floors is a "killer app." Apparently, we'll even be able to see the images from the comfort of the office, or at home. Perhaps we'll noever have to go through the file romm again searching out the "lost film" that we know was just taken. The system will be backed up continuously from a remote location.

However, all is not as rosy as it would seem. One thought that comes to mind is how we're going to be able to function in a power outage. My guess is that unless our X-ray vision glasses arrive, we'll be out of luck- at least for the duration of the blackout. Pretty soon, none of the radiology techs will even remember how to remember film, and the equipment won't be around anyway.

The other issue is for films for the surgeons. For many operations, from the fractured leg X-ray for the orthopedist, to the head CT for the neurosurgeon, to the angiogram for the vascular surgeon, there is no substitute for having the film available. In this current environment of preventing "wrong site surgery," this risk is just too big to take. And the list could go on and on as there really is no excuse for not having the appropriate imaging in the OR for the procedure. In our environment of less invasive procedures, we're even more reliant on our radiology imaging.

The plan is to bring a cart with a double monitor setup to the OR for the procedure. I'm not really sure how the surgeon is supposed to control the computer to see the film, and remain sterile. Perhaps a sterile mouse? (Just kidding!) Also, most CT's and angiograms are more films than will easily fit on even a dual monitor setup. There are also issues of what if the network traffic is slow, or someone kicks out the plug of the setup. Several of my colleagues are up in arms, and plan to bring their patients to radiology offices that still print films that they can put up in the OR.

Stay tuned to see how this all turns out. In my mind, it's real hard to improve on having a printed film up on the lightbox in the OR. While the allure of new technology is great, sometimes a simpler and lower tech solution is the way to go. When people's lives and well being are at stake, we should definitely adhere to simplicity.

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Exceeding Work Limits

A large percentage of first-year medical residents exceeded limits on their work hours intended to reduce fatigue-related medical errors, according to a survey conducted by Harvard Medical School researchers. Violations were reported by residents working at 15 of 16 Massachusetts teaching hospitals.

The study found that 84 percent of 1,278 first-year residents surveyed reported at least one violation in the year after the rules were adopted in July 2003 by the national organization that oversees graduate medical education.

The rules limit residents to working 30 consecutive hours and an average of 80 hours a week, and require them to have an average of one day off every seven days.

Let's just say that when I was a resident, 80 hours a week would have been a part time job to me...

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You Know Doc, It's A Little White Pill...

If I had a nickel for everytime I heard that phrase, I definitely wouldn't have to work so hard. Patients often think that their all knowing doctors know every pill on the market, and can identify it from their description. How about when they bring their pills, but they are in an unmarked bottle without the label?

Staring at the pics in an out of date PDR is so last century. So, now there is a better way. Head on over to Wall's Medicine & Health Center. There, you'll be able to describe the pill by markings, color, and shape. Before you know it, you'll have that pill identified!

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Science Going To New Heights

A 20-member team of British based medicos is preparing to carry out medical lab experiments on the slopes of South Col of Mt Everest, which they said would be the world's highest laboratory.

The medical research team of Xtreme Everest will make the first ever measurements of blood oxygen in the 'death zone', at altitudes above 8,000m where the human body has struggled -and frequently failed to survive-to find out effects on the human body in high altitude.

The team plans to take measurements of oxygen in arterial blood at extreme high altitude above 8,000 metres (26,000 feet) for the first time. It is anticipated that up to ten members of the team will summit Everest...

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Charge Up That Cell Phone

Cell phone use in hospitals reduces medical errors because communication is timelier, and electronic magnetic interference is rare, researchers at the Yale School of Medicine reported this month, the Akron Beacon Journal reports.

The study, which is published in the February issue of Anesthesia & Analgesia, surveyed more than 4,000 anesthesiologists to determine whether cell phone use by medical personnel improves safety. Sixty-five percent of those surveyed use pagers as their primary mode of communication while 17% said they use cell phones, the Beacon Journal reports. The researchers found that 40% of pager users reported delays in communication, compared with 31% of cell phone users.

This came out a few months ago, but I just found it the other day. A few years back, this would be heresy. All the hospitals I go to have those "no cellphone" signs at every entrance, and outside every unit. Was this ever based on anything, or just fear of liability? The benefits of timely communication between doctors, nurses, and other personnel are going to far outweigh the theoretical risks of anything. I used a cell phone next to all kinds of computer equipment and never had any issues. Perhaps research like this will change attitudes, and policy.

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Obesity Vaccine

Tipped through TechNudge:

In what may be the first published breakthrough of its kind in the global battle against obesity, scientists at The Scripps Research Institute have developed an anti-obesity vaccine that significantly slowed weight gain and reduced body fat in animal models. The study is being published in an advanced, online edition of the Proceedings of the National Academy of Sciences during the week of July 31 to August 4.

The vaccine focuses on neutralizing the "hunger hormone" ghrelin. There should be some careful treading as we make a vaccine against the body's normal physiology.

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Intelligent Prosthetics

Advances such as telemedicine and the use of wireless devices in hospitals have become an accepted part of medical technology, but the notion of replacing limbs with computer-powered devices seems more like something out of "RoboCop" or "The $6 Million Man."

Since as far back as the Civil War, prosthetic limbs have consisted of unwieldy lumps of wood, plastic or metal. While some advances in materials have improved comfort for amputees, prosthetics still lack the responsiveness and feel of actual limbs.

Icelandic prosthetic maker Ossur is trying to change that with its Rheo Knee. Billed as the first knee with artificial intelligence, it combines up to 15 sensors, a processor, software and a memory chip to analyze the motion of the prosthetic and learn how to move accordingly. More recently, Ossur introduced the Power Knee, which houses a motor and more sensors. The motor helps replicate some of the action of muscles that have been lost along with the limb.

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You Are What You Eat

Summer is the season of vacations. And vacations often mean time spent on the road or in airports where fast food is the easiest thing to grab when you need a quick meal or snack. The good news is that these outposts of instant gratification have all made great strides toward adding healthier choices to their menus. But the bad news is that the majority of fast food offerings are still loaded with excess calories and fat.

It looks like the breakfast at "Micky D's" leads the pack. I can't say I'm surprised.

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Ultrasonic Hemostasis

Ultrasound technology is best-known for its use in producing images of fetuses in the womb. But focused beams of high-intensity sound waves also can be used to stop internal bleeding--an ultrasound application that Philips Research, with funding from the Defense Advanced Research Projects Agency, hopes to adapt for use on the battlefield, where many injuries become fatal because internal bleeding is not stopped in a timely way.

This technology could also certainly have applications for civilians as well. This would be ideal for situations where a bleeding patient is too far away from a trauma center for rapid transport. Also, splenic salvage, or an additional modality for liver hemostasis come to mind.

More.

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Baby Steps In Bionics

UK scientists have developed technology that enables artificial limbs to be directly attached to a human skeleton. The breakthrough, developed by researchers at University College London, allows the prosthesis to breach the skin without risk of infection. The team says early clinical trials have been "very promising". It hopes the work - which is to be published in the Journal of Anatomy - may help survivors of the 7 July bombings, as well as other amputees. The work paves the way for bionic limbs which are controlled by the central nervous system. In the deer antlers it is very much to do with the structure and shape of the bone, and the porosity of the bone. The technique, called Intraosseous Transcutaneous Amputation Prosthesis (ITAP), involves securing a titanium rod directly into the bone. The metal implant passes through the skin and the artificial limb can be directly attached to it.

Source...

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Driving Under The Influence...Of a Cell Phone?!

Some U.S. states have banned drivers from chatting on their cell phones while behind the wheel, at least without using headsets. But according to the latest research findings, it may be prudent for local governments to stop people from driving and chatting altogether, given that talking on a mobile phone and driving at the same time is as dangerous as driving whilst drunk.

I'm just not sure about this. I don't think that talking on a cell phone, is quite the same as being legally intoxicated behind the wheel. Then again, I had a patient last month that dropped their cell phone, and crashed their car. Now that is a different story...

Source...

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Breaking News...Not!

Fateh Mohammad, a prison inmate in Pakistan, says he woke up last weekend with a glass lightbulb in his anus.

Wednesday night, doctors brought Mohammad's misery to an end after a one-and-a-half hour operation to remove the object.

"Thanks Allah, now I feel comfort. Today, I had my breakfast. I was just drinking water, nothing else," Mohammad, a grey-beared man in his mid-40s, told Reuters from a hospital bed in the southern central city of Multan.

"We had to take it out intact," said Dr. Farrukh Aftab at Nishtar Hospital. "Had it been broken inside, it would be a very very complicated situation."

I hate to have to tell ABC News this, but this is really not that rare of an event, and certainly not worthy of being on their home page. The patient probably said "I was in the wrong place, at the wrong time." I've heard that story many times.

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The Challenge of Psychiatric Diagnosis

From Slate:

In 1973, academic psychologist D.L. Rosenhan sent himself and seven friends and colleagues to the psychiatric emergency rooms of 12 different hospitals. Each told ER workers that for several weeks he or she had been distressed by voices saying "empty," "hollow," and "thud." The testers gave false names and occupations but otherwise accurately reported their histories, which did not include mental illness. In all 12 instances they were admitted to a psychiatric ward. At that point, they stopped pretending to have symptoms. Nonetheless, they were held for an average of 19 days (their stays ranged from seven to 52 days) and were all released with a diagnosis of "schizophrenia, in remission," or something like it. Rosenhan titled his study "On Being Sane in Insane Places" and argued that psychiatric diagnosis has more to do with the presumptions of clinicians, and their tendency to treat ordinary behavior as pathological when it occurs on a psych ward, than with a rational assessment of symptoms.

I hadn't heard of this study before, but it is fascinating. Unlike many other medical specialties, psychiatric diagnosis can be subjective and elusive. When a surgeon removes an appendix, and sends it to a pathologist, it is either read as appendicitis or not. Cardiologists rely on EKG's and troponins to diagnose myocardial infarctions with a high degree of accuracy. There is very little gray area in these two clinical situations.

However, psychiatrists have no "gold standard" test to rule in or rule out schizphrenia. No CT scan, angiogram, or bloodwork is going to definitively rule in or out a diagnosis like schizophrenia, manic depression, or an anxiety disorder. For better or worse, the mental health clinician must diagnose based on the observed signs and symptoms, carefully ruling out other disorders along the way (like hypothyroidism mimicking depression for example).

Based on the "clinical gestalt," the psychiatrist then attempts to fit the patient into one of the known disorders of the DSM. Of course, there are some vague categoreis for things that don't quite fit, like "psychosis nos" (nos=not otherwise specified).

The other pitfall is that once a patient gets labeled with something, even when the symptoms have long resolved, they end up being branded for life. Before a patient gets labeled a schizophrenic, for example, the clinician needs to be quite sure that the patient truly has that disorder.



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Detoxing From Video Games

From The Washington Post:

An addiction center is opening Europe's first detox clinic for game addicts, offering in-house treatment for people who can't leave their joysticks alone.

Video games may look innocent, but they can be as addictive as gambling or drugs _ and just as hard to kick, says Keith Bakker, director of Amsterdam-based Smith & Jones Addiction Consultants.

Bakker already has treated 20 video game addicts, aged 13 to 30, since January. Some show withdrawal symptoms, such as shaking and sweating, when they look at a computer.

I think the manufacturers make these video games to be addictive. After all, they want you to play their game- a lot. I think that in some cases they have done too good of a job at it, and then we have an addiction. While perhaps not as bad as an addiction to heroin or cigarettes, this can be quite destructive to these folks in the end. Perhaps we'll need a Video Gamer's Anonymous at some point if this keeps up.

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