Archives for 2005

CPOE is an Independent Risk Factor for Death?

A nice entry from Dr. Andy: Uh oh Computerized Physician Order Entry

Computerized physician order entry (CPOE) is looked on as a panacea which will decrease medical error, improve efficiemcy, and improve patient safety. Only it looks like it has some major, unintended consequences, like increasing death according to an article titled “Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System: in this months Pediatrics.

Anyway, the findings were suprising and alarming:

Among 1942 children who were referred and admitted for specialized care during the study period, 75 died, accounting for an overall mortality rate of 3.86%. Univariate analysis revealed that mortality rate significantly increased from 2.80% (39 of 1394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation. Multivariate analysis revealed that CPOE remained independently associated with increased odds of mortality (odds ratio: 3.28; 95% confidence interval: 1.94–5.55) after adjustment for other mortality covariables.

Put in plain English, kids transported after implementation of CPOED has a more than 3 fold increased risk of death. Ouch.

(Emphasis mine). Ouch, indeed.

My response is in the comments of Dr. Andy’s post.

“Best” Bad Santa Photo

Several years ago, our younger family made a Ritual Trek to a Mall to ‘See Santa’! The older kids were too old for the experience, and were there mainly because they had to go, and they wanted to see the littlest with the Big Guy.

Youngest daughter was then more than a little skittish and risk-averse, so why we thought this would go well is, in retrospect, completely beyond me.

Here’s how it went:

Sanat wants to cry, too

In discussing this with friends and family over the years, kid meltdowns with Santa seem to very frequent. If you’d like to share your Bad Santa Picture, send me a link (or send me the pic and the story).

Be nice to the Santa surrogates, they earn their pay.

Update! Thanks to reader Celsey, here’s a gallery of 42 Bad Santa photos from

December 7th is Pearl Harbor Day

Pearl Harbor Day

Thank a Pearl Harbor vet. They’re getting hard to find.

MedBlogs Grand Rounds 2:11

The Examining Room of Dr. Charles: Grand Rounds 211

Welcome to Grand Rounds, the weekly highlight show of medical blogging. You will be inspired, discouraged, and enlightened by these unique pieces as contributed this week by doctors, nurses, patients, and healthcare professionals who’ve got something to say.

Tales of the Examining Room And, he has a book out, which would be a good Christmas present.

Coffee and Your Liver

Again, coffee is found to be good for you. This from the Washington Post:

Study Suggests Caffeine Can Help Liver

Monday, December 5, 2005; Page A06

Coffee and tea may reduce the risk of serious liver damage in people who drink too much alcohol, are overweight or have too much iron in the blood, researchers reported yesterday.

The study of nearly 10,000 people showed that those who drank more than two cups of coffee or tea per day developed chronic liver disease at half the rate of those who drank less than one cup each day.

ABEM: EM Docs Not Participating in Life Long Self Assessment

The American Board of Emergency Medicine (ABEM) is the Board Certifying organization in Emergency Medicine for those who are residency trained, which is the current standard for Emergency Physicians. Therefore, the ABEM is Important, and is charged with initial and recurrent certification of EM docs.

In the good old days, a residency grad would get Board Certified initially, then retest every ten years (and most specialty boards still do that). ABEM is one of the first to embrace Lifelong Learning and Skills Assessment (LLSA), which in the current iteration means reading several articles and then taking an online, open book test. Not scary, and probably a good idea (the articles chosen so far are pretty good, though the timing of the Nesiritide article could have been better).

So, it’s been in place for nearly two years. How’s it going? Here’s how:

Well. Not good. Not good at all.

Yes, diplomates can wait 8 years and take all the tests at once (which is against the spirit of the arrangement but still legal), and that’s stupid, frankly. I have no idea why the numbers are this low, and I guarantee 80% of the currently board certified docs aren’t intending to just give up their board certification at the end of their 10 years.

My personal opinion is that the horrible completion rates are a mixture of lazyness and hope (and that’s just a guess, I have no independent polling). Lazy so they don’t have to read the articles assigned and figure out how to get to the site, pay the money and take the test, and hope that if enough diplomates don’t play the Board will be forced to rescind the whole system. I think that’s dreaming and isn’t going to happen.

I also predict that my current study manuals will find some very receptive buyers in about 6 years, as the dawn occurs to a lot of EP’s.

For the record, I passed 2004 and have registered for the 2005 test, but haven’t finished it.
Update: I finished it.

AAEM Reviews Cases, and Names Names

I’ve written before that one of the things we, as a Profession need to do to decrease meritless malpractice cases is to put our own house in order as regards expert witness testimony. I do not advocate a wall of silence or a parroting of the ‘party-line’, but I’m all for exposing our erstwhile ‘colleagues’ who will give expert testimony that’s at odds with provable standards and actual practices.

AAEM has decided to join the party, explaining it thusly:

In order to file a malpractice claim, many states require plaintiffs to have an opinion from an expert that malpractice has occurred. A number of these so-called experts are physicians who seem willing to make any statement, no matter how outrageous, in support of a malpractice claim. These physicians can profit handsomely from their willingness give such testimony.

Alarmingly, a number of leaders in our specialty have chosen to supplement their income by giving “expert” testimony that is unfounded in current medical standards and practice.

AAEM has responded to suggestions by several members by creating this web site. It is designed to bring to light testimony by expert witnesses that is remarkable either because of its spurious nature or because it is particularly helpful to the emergency physician defendant. It is hoped that by publicizing such testimony, and the individuals who offer it, emergency physicians may find some measure of relief from the ongoing crisis.

Unlike the ACEP review, AAEM is naming names. AAEM has helpfully included the name of the plaintiff’s expert witness (which I’m going to leave out of this post, for now).

A look at the testimony in the case does make me, as a practicing EM physician, say “huh?” Here’s some of it:

Page 33 – line 11:

Question: “And have you treated patients like Mrs. Walker who have come here with these kind of symptoms with tPA?”
Answer: “All the time. I mean, unfortunately, it’s all the time. Not daily, but probably three or four times a week.”
Comment: The reviewers were surprised that a physician would claim to give tPA so frequently. Giving it at such a rate would probably exceed the usage at the busiest centers in the world. This seems like a wild exaggeration.

My ED sees about 75,000 a year and we don’t give tPA for stroke 4 times a month, let alone any one physician giving tPA for stroke 4 times a week.

Want to keep the roaches down? Turn on the lights. They don’t like the exposure, and for that reason ACEP and AAEM are to be commended for their efforts.

RSNA: Coffee Boosts Short Term Memory

Another reason to have a cup:

CHICAGO, Nov. 30 – A cup of coffee is good for the memory, at least the short term memory, according to research reported today.

In a study of 15 healthy men ages 26 to 47, functional magnetic resonance imaging (fMRI) detected significant activity in the brain’s memory centers 20 minutes after the men consumed 100 mg of caffeine, according an Austrian study reported at the Radiological Society of North America meeting here.

The activity was significantly greater than men who were imaged after consuming a matched placebo (P<0.05), said Florian Koppelstatter, M.D., of the University Hospital Innsbruck. He said the fMRI scan detected activity in the anterior cingulate cortex of the brain, which is responsible for some short-term memory functions.

This was by the Radiological Society of North America, and not Folgers, so you know it’s good.

Bird Flu Symptoms

Just so you know: there have not been any cases of bird flu in the US. That having been said, there’s a lot of work going on to get ready for it.

Today: how to tell if you have bird flu

Center for Disease Control has released a list of symptoms of bird flu. If you experience any of the following, please seek medical treatment immediately:

1. High fever

2. Congestion

3. Nausea

4. Fatigue

5. Aching in the joints

6. An irresistible urge to crap on someone’s windshield.


via Dear Aunt Sue

MSSP Nexus Blog Proposes: The Bloscars

As a refinement to the Medgadget MedBlog Awards, Rita at MSSP has an idea:

MSSPNexus Blog: Academy of Blogging Arts and Sciences

The Bloscars

Since MedGadget started this, the onus is on them to create, manage, and of course fund the Academy of Blogging Arts and Sciences.

Nominations shall be restricted to select members of the Academy. I’m not sure how they’ll be selected, that would be Medgadget’s problem to figure out. (That’ll teach you for coming up with a good concept!) Once the field has been narrowed to no more than five nominees in each category, all members of the Academy of Blogging Arts and Sciences shall be permitted to vote for one Bloscar winner in each category.

I think it’ll get somebody a nice cease-and-desist letter from the Oscar folks, but as there’s only about 30 of us, what are the chances of that?

Emergency bypass surgery on angioplasty patients drops 90%

I can go two weeks and not find anything stimulating to comment on, then there’s a day like today.

Emergency bypass surgery on angioplasty patients drops 90% Cardiac Stent: original from

Decline seen at Mayo Clinic even as physicians expanded angioplasty to sicker patients

When life-threatening problems occur during angioplasty procedures, doctors may perform emergency coronary artery bypass graft surgery, but data from the Mayo Clinic indicates that need to send patients to emergency surgery has dropped sharply, according to a new study in the Dec. 6, 2005, issue of the Journal of the American College of Cardiology.
‘Our review of almost 25 years of data on angioplasty suggests that there has been a dramatic reduction of almost 90 percent in the incidence of coronary artery bypass graft surgery following angioplasty; and this is despite the fact that more recently we are performing angioplasty on very high risk patients,’ said Mandeep Singh, M.D., F.A.C.C., from the Mayo College of Medicine in Rochester, Minnesota.

‘We knew there had been a reduction, but the magnitude of the reduction was a surprise to us,’ Dr. Singh said. ‘The bypass surgery rates, which were close to 3 percent, came down to 0.3 percent in the most recent time period.’

Dr. Singh said the fact that angioplasty is being offered to sicker patients now makes the reduction even more remarkable. Patients requiring emergency surgery in the most recent study period had a higher prevalence of high blood pressure and heart failure, and they were more likely to have undergone previous procedures, compared to patients in the earlier study periods.

Dr. Singh said he believes stents may be responsible for much of the reduction in the rate of life-threatening problems during angioplasty procedures.

However, among patients who did suffer serious problems during angioplasty and had to be sent into emergency surgery, the researchers did not see an improvement in survival. Death rates were statistically similar in all three study periods, ranging between 10 percent and 14 percent. Dr. Singh pointed out that there were only 41 deaths among patients who underwent emergency bypass surgery, including just two during the 2000 to 2003 study period. He said such small numbers make it difficult to calculate useful statistical comparisons.

‘The assessment of elective PCI without on-site bypass surgery underway in some states is a step in the right direction. But, choosing the right metrics is challenging. The only meaningful comparison between hospitals with and without on-site surgery is the rate of death or urgent transfer to another facility within a pre-specified period of time after PCI. One proposal that mixes acute events with late endpoints like repeat revascularizations is manipulative and misleading,’ he added.

This is really good news for everyone, cardiac surgeons included (they don’t want to be operating emergently anyway, and especially not on people who are already super-sick with vessels so bad they can’t be opened in the cath lab). I, for instance, really hope that when I have my MI (family probability) they can get me opened and stented in the lab, and not spend an hour in the lab then go and have my chest cracked for a bypass.

Also, this study going on with emergency caths in hospitals without in-house emergency bypass surgery is going to be very interesting to watch. Personally I hope it’s shown to have an acceptable risk/benefit ratio, but that study is only starting.

Good news, and progress, all around.

Stent picture from St. Michael’s Hospital, Tononto, Canada.

From Medscape: Are We Really Better Off With HIPAA?

From Medscape, an editorial by their founder: Are We Really Better Off With HIPAA? There’s a video of Mr. Frishauf reading his editorial, slowly, if you want to watch, but the entire text is under the video box. Original Image from PrawfsBlawg

Are We Really Better Off With HIPAA?

Whether you’re an American clinician or patient, there’s no escaping the Health Insurance Portability and Accountability Act (HIPAA). Republicans and Democrats assured us it would make healthcare better.

But has it?

Unless you’re a HIPAA consultant, a compliance officer, or some other bureaucrat, the answer is generally no.

The thing that bothers me most about HIPAA is its expensive, annoying, and — in the end — meaningless implementation. Clinicians have to get all patients to sign forms, which they then file, or they get into trouble, and could face huge fines. Insurance companies must do the same, but then require patients to forget about their privacy if they want insurance. So most do.

Hospitals cringe at the thought of HIPAA fines. Their well-paid consultants design elaborate, expensive systems to ensure compliance.

I will concede one good thing about HIPAA, and that’s the health insurance portability.
Title I protects health insurance coverage for workers and their families when they change or lose their jobs — and this part of the law is working.

But the much ballyhooed “privacy” parts of the law are a failure that could easily be repealed with financial savings to healthcare and no adverse effects that I can think of. In fact, US medicine without these provisions could be better, as information sharing would be easier. And that usually helps patients a lot more than it hurts them.

That’s my opinion, and I’m Peter Frishauf, founder of Medscape.

That’s my opinion as well. Mountains of paperwork, which serve only to further erode public trust in government (another meaningless form you HAVE TO SIGN, thanks for watching out for my rights) and put one more impediment in the wheels of progress.

Also, let’s not forget that the first (and as far as I can tell by Googling, only) use of HIPAA was to convict a hospital employee of identity theft. He should have gone to jail, but there’s already laws against identity theft.

And, it’s here to stay. The continuous creep of government intrusiveness into our lives continues no matter which part is in power in Washington. There’s no chance this will be overturned, politicians lack the “Oh, that was a mistake, and we’ll fix it” gene.

Image from PrawfsBlawg. Don’t want to tick off the lawyers.

MedBlogs Grand Rounds 2:10

It’s Time For Grand Rounds

Just when you thought you couldn’t stomach anymore Thanksgiving goodness, it’s the Thank-You-Kindly edition of Grand Rounds! (Version 2.10, but who’s counting.) Publicized in part by Medscape, thanks!

A nice job, and a lot of links!

New York EM Docs Sacked

I think this is entirely wrong, unless actual wrongdoing is alleged:
this pink slip's for you!

NUMC to fire ER staff

November 29, 2005

Nassau University Medical Center officials yesterday announced plans to replace nearly all their veteran emergency room doctors within six months, saying the physicians’ training and credentials are not up to today’s standards.

Union leaders who represent the doctors immediately accused administrators of violating a deal to forgo layoffs at the public hospital in East Meadow. They said the firings are the first step in an effort to privatize the emergency room. The hospital entered into an affiliation agreement with the nonprofit North Shore-Long Island Jewish Health System in the summer.

[ Interesting local hospital politics, only partially hinted about, removed ]

The hospital has decided to hire doctors with national medical board certification and residency training in emergency medicine, who could handle a wider array of cases, Kane said.

Dr. Joan McInerney, who was asked to step down as chairwoman of emergency medicine, broke into tears and declined to comment on her job yesterday, saying she had to call her lawyer.

But McInerney said she disagreed with the decision to replace all the doctors at once, and advocated hiring emergency specialists gradually. “None of them deserve that,” McInerney said of the doctors.

Officials said their move would create more flexibility in a department that sees 80,000 patients a year.

The hospital’s 20 full-time emergency room doctors specialize in non-emergency fields, including internal medicine, surgery, gynecology or pediatrics. Only two doctors have the training and certification in emergency medicine that would now allow them to stay.

Asked whether the doctors would be offered other jobs in the hospital, Kane said, “I don’t know that there will be vacant positions elsewhere that they would qualify for.”

McInerney was asked to step down by Kane and Dr. Steven Walerstein, the senior vice president for medical affairs but she has not yet done so, said Ron Gurrieri, the union’s first vice president. McInerney is board certified in emergency medicine, but does not have residency training in that area.

The field of emergency medicine developed in the 1960s. The first certification was not until 1980, and there were few residency training programs then. About 62 percent of practicing doctors are board certified or residency trained in emergency medicine, according to the American College of Emergency Physicians. Older emergency room doctors often specialized in another area.

At Nassau University Medical Center yesterday, the emergency room doctors said they could not comment, for fear of retribution.

“We’re outraged,” said one doctor who spoke on condition of anonymity. “Obviously we feel that we’ve provided good services to the hospital, and now they’re changing our terms of employment, and they want to get rid of us.”

For the record, I believe new hires in ED’s should be EM Residency Trained, and Board Eligible / Certified, with an expectation that those who are eligible will get themselves certified. That having been said, I’m not in favor of sacking an entire ED physician cadre based on ‘changing standards’. If they’ve been credentialled at their hospital, then they shouldn’t be removed unless some cause is shown. (I don’t have that protection, by the way, most EM docs don’t. I’m speaking of the Ideal World here).

Have a look at their ED’s site. I’ve never worked in an ED that had this level of division, and wonder if this isn’t what the move is about. [Speculation alert] Consolidating the operations of 7 separate EDs into one (or two, Surgeons are notorious turf-defenders) could possibly save some money, and EM trained docs can staff all the areas they describe. [/Speculation].

A bunch of CVs are getting polished tonight and faxes will be flying tomorrow.

You’d think the name would have been a warning…. – MacDonald charged in Wendy’s heist – Nov 28, 2005

MANCHESTER, New Hampshire (AP) — He works at a Wendy’s, and his name is Ronald MacDonald — but now he may be known as the Hamburglar.

Two workers at a Wendy’s in Manchester, New Hampshire, have been charged with taking money from the safe. One of the suspects is Ronald MacDonald.