Friday, December 28, 2007

We've Got a Hasselhoff in Room 13

Several media outlets ran stories recently about the British Medical Journal's Christmas edition which, in keeping with its tradition, published lighthearted articles on the culture of medicine. One of these was a short list of new medical terminology. There's some good stuff in there, including the terms "blamestorming" (a group of doctors trying to find a scapegoat for an egregious error), "tesiticulation" ("the holding forth with expressive hand gestures by a consultant on a subject in which he or she has little knowledge") and "Jack Bauer" (a doctor still up and working after 24 hours on the hob) but the kicker of the compendium was "Hasselhoff."

The term "Hasselhoff" refers to a patient with an injury (or injuries) that are not plausibly related to the explanation given for them. David Hasselfhoff (of Knight Rider and Baywatch fame) was injured at a London hotel in 2006 while shaving. Shaving, at least, was the explanation he gave for a head injury and a severely injured right arm (with tendon and artery damage). Hasselhoff's story (to this day) is that he hit his head on a bathroom chandelier while shaving, which caused the chandelier to break and to send a shard of glass through his arm. It's hard to imagine a plausible manner in which this could have occured; was he wearing a pair of stilts while shaving? Or trying to use the chandelier glass to get a closer look at his nose hair?

Recently, we had a "Hasselhoff" in Room 13 of our emergency department (ED); a middle-aged man who had hurt his ribs and chest while getting out of bed to get a glass of water. Perhaps he was a little tipsy, he said, and had stumbled against a railing. As the x-rays revealed, there were more to his injuries than just a banged-up rib cage. This guy was walking around with numerous broken ribs, including the first and second (which are very difficult to break) and a "flail" area of the chest - where the ribs paradoxically sucked in (rather than expanding out) with inspiration. There was no doubt that this man had suffered a high velocity and high impact injury - but he, in vintage Hasselhoff form, stuck to his story (even when the admitting surgeon, a gruff and no-nonsense type of guy, called bullshit.) We kept waiting for the police to show up, inquiring about a man who had abandoned his car in a precarious position, but our curiousity was not to be satisfied. Like Hasselhoff's mysterious chandelier incident, this fool's story may remain fuel for an active imagination.

Sunday, December 16, 2007

That Crazy Flu Bug

From the country that brought us video game induced seizures, now comes flu-induced delirium.
Japanese children are running around like crazed lunatics and exhibiting self-destructive behavior. Now, I've never been to Japan, but I can tell you that as the father of a 2 year old, this does not strike me as particularly unusual. Nonetheless, the evidence from Japan seems to implicate the use of Tamiflu (oseltamivir) in flu patients with neuropsychiatric disturbances that include seizures, delirium and mysterious falls from tall buildings.
Four Japanese children under 16 have died from falls and this has the FDA looking into 55 incidents (no deaths) of abnormal behavior in U.S. patients taking Tamiflu since it was approved in 1999.
Apparently, and this was news to me, the use of Tamiflu is considered standard of care in Japan for patients with the flu (75% of the 48 million prescriptions written have been for Japanese patients). This is odd, because the drug is really not all that effective - it is only helpful if given early in the course of illness and only able to diminish the duration of symptoms by 24 hours or so. Roche, the maker of Tamiflu, has brushed off these incidents - arguing that they are the product of the viral (flu) infection rather than the medication.
Regardless of the cause, however, it seems prudent to limit the use of Tamiflu to a select group of patients: those with significant underlying diseases at high risk for complications who present early in the course of their flu bug. Everyone else should consider getting vaccinated (if you haven't done it, now would be a good time) and remember that there's nothing crazy about the notion that good hygiene can help control the spread of disease.

From the New York Times:

Friday, December 14, 2007

Unhealthy Egos

The November 27th New York Science Times section led with a story entitled “The Feud,” by Lawrence Altman. This piece is an excellent reminder that big egos can be unhealthy; even in the field of medicine where patient care is supposed to trump personal ego. “The Feud” addresses the relationship of two of the leading surgeons of the 1950’s and 60’s – Michael A DeBakey and Denton A Cooley – both legends of the operating room and pioneers of cardiovascular surgery. The conflict between them began when Cooley pilfered an artificial heart from DeBakey’s lab at Baylor Medical College and placed the half-pound piece of plastic in the chest of one of his own patients. DeBakey was informed about the theft from colleagues at a conference and was none too pleased. “I never quite understood it other than his ambition was almost uncontrolled,” DeBakey later said, adding that Cooley “kind of suffered from the fact that I was considered more prestigious than he was.” Cooley justified his unprecedented betrayal not by invoking patient care (his patient gained just four and half days of life out of the ordeal) but rather on the self-indulgent (he was doing more heart operations than anyone else so therefore deserved to be the first to implant an artificial heart) and the patriotic (he didn’t want the Russians to beat us to this milestone). The fallout from this feud was massive and not only caused bad blood between DeBakey and Cooley for decades, but may have also setback the development of implantable cardiac assist devices by 10 years or more. Now, Altman reports, Cooley (age 87) and Debakey (age 99) have finally made peace; just in time, a cynic might say, to become demented and forget that the whole thing happened.

The issue of ego is not frequently discussed in medicine, but doctors are human and humans have egos. And egos affect decisions, sometimes for the better and sometimes for the worse. I’ve seen it myriad times, both in my training and later in my community practice. Especially at academic medical centers, specialty services often have “pissing matches” regarding which service should admit a particular patient to the hospital. At the heart of these conflicts is a desire to avoid work but the dispute often degenerates into a battle of ego. The surgeon, for example, may demand that the medicine service admit a patient with an inflamed gallbladder, not so much because this is in the best interest of the patient, but simply because they are the surgeons and have been indoctrinated with the idea that other services are not their equal. Mortality and Morbidity (M&M) conferences often become a theater in which faculty members can demonstrate how smart they are to their trainees and each other. I recall several M&M conferences from my residency in which a fellow resident who was presenting a case with a bad outcome was nearly brought to tears by the barrage of second-guessing from retrospectoscope-enabled faculty. Physicians should and must have a process of vetting cases in which patient care goes awry, but to do so in a manner in a way which serves to placate ego does not make sense.

Physician-patient interactions can also become colored by physician ego. I see this most commonly if the patient requests (or demands) a certain treatment. Often, the patient is being unrealistic, but not always and sometimes it is not so much the nature of a patient request, but its manner that irritates physicians. I have certainly fallen victim to this; a patient arrives having googled the bejeezus out of their symptoms and having formed a definite opinion about their diagnosis. If I feel like I am being treated as nothing more than the gatekeeper to their preferred treatment, rather than a professional with years of training, I may push back. I can only imagine that more veteran physicians, who trained in an era in which physician judgment was rarely questioned and in which medical decisions were made primarily by doctors rather than through a “shared” approach, find this type of internet-savvy patient to be bedeviling.

There are other examples, but I won’t belabor the point. I will just conclude with a variation on an age old maxim that applies equally to physicians (dealing with each other or patients) or patients (who want something from their doctors): you can cure more colds with honey than with vinegar.

Thursday, December 6, 2007

The Cursa of the “Mursa”

A new germ scare has infected the American media. Five years ago it was the mysterious SARS, a couple years ago it was the civilization-threatening H5N1 Avian Flu and now it is the omnipresent and utterly malicious superbug known as MRSA (pronounced “Mursa”). MRSA (methicillin-resistant staphylococcus aureus) is everywhere; not just living in the upholstery of ICUs, the creases of the linens at grandma’s nursing home, the computer keyboards of your local emergency department; but also in the saunas of the downtown YMCA, the mats at the neighborhood yoga studio and the nostrils of about three-percent of the U.S. population.

Emergency Department personnel across the country are well-acquainted with MRSA as the profile of an infected patient has become classic: a previously healthy person with an unusual skin disturbance, usually in an unusual location. Maybe they call it a boil, a zit, or a spider bite, or maybe (if it is in an intimate location) it is referred to obliquely as “pain down there.” Most of these infections are easily treated with simple I&D (incision and drainage) and the patient can be sent home – sometimes with antibiotics, sometimes not. In some small, but not insignificant percentage of cases however, a MRSA infection attacks differently – in the lungs, the blood or the deep muscle layers. These potentially deadly aberrations are becoming more common and are the fuel for the recent frenzy of MRSA stories in the media. An October report from the CDC put the yearly MRSA death tally at 19,000 in the U.S. alone. This is indeed significant, especially when you consider that this number is twenty times the total human mortality from the H5N1 Flu and SARS combined.

About a month ago the mechanism for MRSA’s unusual method of infection was discovered. As it turns out, MRSA (and in particular the form of MRSA found outside of hospitals) plays a nasty trick on the body’s immune system. White blood cells from the immune system are drawn to the site of infection by a cluster of proteins (called phenol soluble modulins) that are released by MRSA, then these immune cells are destroyed by the same proteins – in a process that causes them to swell and explode – like a Ziploc bag of mashed potatoes left in the microwave too long. This provides an explanation for the strange phenomenon that emergency physicians like me have observed – MRSA skin infections that are miniature pus volcanoes, rising from otherwise pristine arms, legs, and nether regions and just waiting to erupt.

In the December 1st issue of The Economist I read about a newly emerging strain of MRSA, the so-called non-typable or NT-MRSA – which is not to be confused with other alphabet soup strains such as HA-MRSA (hospital-acquired MRSA) and CA-MRSA (community-acquired MRSA). NT-MRSA is an especially pig-nacious variation. Literally. NT-MRSA is a strain resistant to a class of drugs called tetracyclines that have up to now proven to be a relatively reliable antagonist for MRSA (86% successful treatment rate in a study out of Oakland, California). Tetracyclines along with other antibiotics, vaccines and insecticides are heavily used in pig farming to help fatten the swine (preventing infection means preventing loss of porkable meat). It is thought that this usage has caused the development of the NT-MRSA strain. A Dutch study cited by The Economist has found NT-MRSA in 39% of Dutch pigs and 81% of Dutch pig farms. A Canadian study found NT-MRSA in 20% of Ontario-area swine farmers. American hoggers also use antibiotics, so U.S. pig farms are surely not immune (if you doubt this, click on the link below to a 2006 Rolling Stone story about hog farms). Findings like this are too often described as “alarming” or “shocking,” but I don’t think the discovery of NT-MRSA fits in either of these categories (except perhaps, if you are a pig). Tetracyclines are not considered frontline drugs for treatment of MRSA – there are already other more effective options. But, it is never good to create antibiotic resistance, and especially if you do so not by helping people but by trying to make better bacon. Occasionally in my line of work, I will prescribe antibiotics to a patient even if I don’t think they need them. Usually, these patients have come to the ED with a clear agenda and will be disappointed, and perhaps angry, if that agenda is not fulfilled. In these situations I usually feel a little guilty, as I know I am contributing to the superbug problem. Now, I no longer have to think of myself as the villain – the pig farmers will do quite nicely.


Monday, June 4, 2007

First Aid Update: Extract the Extractor

Did you know that a backcountry hiker is more likely to die from eating a peanut then from a rattlesnake bite? In the United States, allergic reactions to the usually tasty (but occasionally deadly) peanut are ten times more lethal than venomous snake bites. In fact, out of an estimated 8000 snake bites each year in the U.S., there are only 8 to 10 deaths. Nevertheless, many aspiring backpackers (including me) have featured snakebite preparation as an integral piece of their first aid planning.

Before hiking the Pacific Crest Trail in 2000, I became intrigued by a product called the Sawyer Extractor – a suction device designed to pull venom out of a fresh wound. The Sawyer Extractor is marketed as a cure for all sorts of bites and stings – snakes, bees, wasps, ticks, spiders, scorpions, mosquitoes, and even jellyfish. Early tests in rabbits suggested that the Extractor was an upgrade from the no-longer-recommended “cut and suck” method popularized on TV and in the movies. A search on the Internet (i.e. via my colleague “Dr. Google”) unearthed numerous corroborating testimonials. For example, Brenda in Ohio claims to have used the device after being stung by a wasp 15 times. “Within fifteen minutes,” writes Brenda, “my husband was able to extract the poison out of all of the bites and by the next morning you could not see welts or any redness, stinging or itching at all. I am definitely sold on your product!” Elsewhere on the Internet, the Extractor is touted as the only “medically recommended” first aid device for snakebites.

At the time, Brenda had me convinced that the Extractor was a promising treatment option and good insurance against a rattlesnake encounter gone awry. So, I tried to order one but, it seemed, I wasn’t the only one to have that idea - the Extractor was out of stock.

I was disappointed to begin my hike without such a seemingly indispensable tool. Today, however, I’m glad I saved myself the trouble (and the $14) of adding the Extractor to my med kit. That’s because a recent study published in the peer-reviewed medical journal Annals of Emergency Medicine has called the utility of suction devices into serious question.

In the October 2004 issue of Annals, Dr. Michael B. Alberts and his co-investigators at the Community Medical Center California in Fresno report the results of the first human trial of the Sawyer Extractor. Using hypodermic needles 1.7mm in width (equivalent to the fang of an average rattlesnake) the researchers injected a protein-rich solution attached with a radio-labeled tracer into the lower legs of eight male volunteers. Three minutes after the injection of this “mock venom” the Sawyer Extractor was applied and suction initiated. Fifteen minutes later, the Extractor was removed and its contents analyzed for radio-active counts. The investigators hypothesized that if the suction was effective, they would be able to retrieve a significant amount of the injected mock venom (measurable via the radio-active counts).

The results of the study are succinctly summarized in the title of an editorial that accompanies the paper in Annals. It reads “Snakebite Suction Devices Don’t Remove Venom: They Just Suck.” It’s unusual for medical professionals to write with such clarity, but in this case the editorial author, Dr. Sean Bush, captures the essence of the study without the clutter of medical jargon. When Dr. Alberts and colleagues analyzed the blood and fluid retrieved from the suction, they found just that – blood and fluid – with little evidence of mock venom. In fact, they only picked up an average of 38.5 out of 89,895 counts loaded. That is 0.04%, or 4 out of 10,000. Not so good. The investigators also measured mock venom load in the leg, lungs and pelvis of the volunteers after extraction and found that in the best case scenario, the Extractor might be responsible for a 2% reduction in total body venom. Still not so good.

Dr. Bush (whose name some may recognize from Animal Planet’s Venom ER) and Dr Alberts agree that there is NO evidence to support the use of the Sawyer Extractor. In fact, there might even be a danger to using the device – the suction cup has been implicated in skin damage due to excess pressure and with longer healing times.

Thus, the Extractor is not sounding indispensable any more. In fact the device is probably an unnecessary four ounce addition to a hiker’s first aid kit.

What then, should snake-wary hiker do? Unfortunately, modern medicine doesn’t have a lot advice to offer. Field treatment of venomous snake bites has become a controversial area of medical care and several proposed treatments, such as the use of tourniquets and compression isolation, have failed the tests of time and experience.

Nowadays, most emergency providers are in agreement that those that want to be prepared for the worst will need to have technology on their side. “The best first aid for snakebite,” writes Dr. Bush “is a cell phone and a helicopter.”