Today’s New York Times finally caught up with an issue previously discussed HERE.
The NYT notes that the federal government is mis-using institutional review boards to thwart the implementation of checklist systems and deny funding for the programs. The same checklist systems have documented efficacy at decreasing patient injury and complications.
See the NYT story HERE.
Awareness is a known complication of anesthesia. The reported incidence varies but is probably between one in one-thousand and one in ten-thousand. It’s real. For those who experience it it varies from a horrible, terrifying experience to one of nonchalant acceptance.
The recent movie, Awake, highlights some of the effects of awareness under anesthesia in a typical, minimally accurate hollywood stylization.
Recently, I found an entire website dedicated to anesthesia awareness (more properly termed awareness under anesthesia). What struck me most was the following quote from the site:
Until the consistent use of every possible precaution (both human and equipment) to avoid awareness becomes routine, and such precautions are something of which a patient can be absolutely assured, this Campaign will not rest.
The quote is attributed to the organization’s president. I have to confess that it makes good press. It no doubt helps keep the president in public appearances. But, it makes terrible public policy.
First, there is no meaningful evidence that any monitor, except a well-trained anesthesia provider, decreases the incidence of awareness under anesthesia (Sebel P, Bowdle TA, Ghoneim MM, et al. The incidence of awareness during anesthesia: a multicenter United States study. Anesth Analg 2004;99:833–9). In fact studies sponsored by the number one maker of “consciousness monitors” have actually shown increases in the incidence of awareness.
Second, by some estimates it would cost as much as $400,000 to prevent a single incident of awareness (Anesthesiology. 2001 Mar;94(3):520-2). At a rate of one in one-thousand cases that adds an extra $400 to every surgical procedure under general anesthesia. Under the best of circumstances the same experts estimates yield an increase of at least $200 per case. How many patients want to pay that amount? At a time when the average American complains about the cost of heath care this seems a frankly frivolous expenditure. If health care expenditure is not increased then those funds must come from somewhere else- what testing or therapy should we eliminate?
Third, it’s great to claim that everyone should get everything, all the time. That leaves us with the “who will pay?” question. More services can be provided in only two ways the first is increasing cost, the second is decreasing other services (hence cost).
Finally, and what I find most appalling, is that physicians, (even anesthesiologists) have bought into this. Responsible physicians have an obligation to patients and an obligation to one is an obligation to all patients. The first step in any cost-effectiveness analysis is demonstrating the effectiveness of the test or monitor in question. The effectiveness of “consciousness monitoring” is far from settled.
I personally don’t want anyone to use a “consciousness monitor” when I have anesthesia. I certainly don’t want a provider to rely on a single monitor that won’t reliably increase longevity or life-enjoyment but may bankrupt our health care system. The extra $2-400 per surgery could do that.
Think about what we ask for. If monitors like this were really good- that is reliable and cost effective then they’d be in use everywhere already.
I’ve previously written about the apparent assult of a patient by the ER staff at New York Presbyterian Hospital.
Abuse of patients is not limited to New York. A recent article indicates that Hollywood Presbyterian Hospital dumped a mentally ill, homeless, paraplegic man in the street. The patient was dumped in downtown Los Angeles. Apparently Holywood Presbyterian thought he’d simply blend in with the twelve thousand other homeless people. Presbyterian was wrong. A paraplegic man in the gutter gets noticed even in LA.
Readers already know that abuse of patients is not OK. I hope Californians, and Angelinos specifically, are calling the California Department of Health Care Services to complain. Everyone must take charge of health care.
It’s your health take care of it.
Many readers know I practiced medicine in Canada. While I was there the mortality on the waiting list for heart surgery was 7 times the mortality from the operation (at least at my hospital, 20 years ago). It was a great system as long as you were healthy and didn’t actually need care. If you were sick it was completely inadequate. In fact I always maintained an “escape plan” so I could return to the US for care. Rationing is an obligate part of any single-payer system. The government is no different. Unfortunately once it’s a single-payer system you have no choice.
Now it looks like the health- insurance experiment in Massechusetts is failing just a spectacularly. Apparently the law offers no real benefit to patients but has resulted in windfall profits for insurance companies. So mush profit, in fact, that Blue Cross, the state’s largest insurer, is reaping a surplus of more than $1 million each day, and awarded its chairman a $16.4 million retirement bonus even as he continues to draw a $3 million salary.
It’s another taxpayer-fund travesty that does not improve health care or health care access. It continues to benefit the “big guys” while everyone else continues to suffer. Read the whole story HERE.
A recent article from the NY Times City Room is disturbing on many levels. According to the article a 38 year old man was taken to the ER at New York Presbyterian Hospital. After arrival he refused a rectal exam. Then the ER staff held him down and examined him. The reasons given for the exam are almost as obscenely stupid as the whole event. As you might guess a struggle ensued.
Subsequently, the patient (victim?) was sedated (rendered unconscious) and intubated. When he awoke, he was arrested.
This behavior is simply not acceptable. New York Presbyterian Hospital is a teaching hospital. I can only wonder where were the experienced attending physicians? Who was in charge? l would hope that this was a horrendous miscarriage of medical care perpetrated on an unsuspecting patient by undertrained, inadequately supervised trainees. But the reality is that it may not be.
The courts have refused to step in to dismiss the subsequent suit by the patient. If the facts are borne out then swift and severe discipline is justified. Even physicians must learn that “no means no.”
If a physician fails to honor your refusal of consent then you need a good lawyer and a call to the state medical board. It’s your body and your health. Take it seriously and take charge.
An enormous quantity of healthcare information exists on the internet. Unfortunately an enormous quantity of dis- and mis-information also exists. Distinguishing between the two may be very hard for laypersons. Despite the comments of Dr. Haig (see previous posts), helping you sort this out is your doctor’s job. In the old days you got infomation from Reader’s Digest and other print sources- doctors didn’t complain then.
In addition to Safer Health Care there are other resources. Read about some of them HERE.
It’s your health. Take an active role in your care.
Readers know that hospitals are very dangerous places, especially if you’re sick. Many hospitals have little or no system in place to prevent recognized illness or injury to patients. Urinary catheters- those infamous Foley caths- that everyone hates, are a frequent source of nosocomial infection. Nosocomial infections are those acquired in hospitals.
Now there’s more questions you should ask of your hospital:
What is your foley catheter infection rate?
What is your nosocomial infection rate?
How many of your patients are infected with MRSA?
These are important questions that may affect your survival. If the hospital can’t or won’t give you answers then maybe you should be in another hospital…
Every now and then a physician goes so far out of his way to prove himself a jerk that I fear for the survival of modern medicine. When this happens I think of the old saying “Better to be thought a fool, than to open your mouth and remove all doubt.” Scott Haig should have observed this advice. Instead Haig rants bout patients who “google.”
As an aside, Haig’s by-line claims he is “Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons.” Columbia seems not to know that since he’s conspicuously absent from the orthopedic surgery webpage (yup, I googled Haig). Not that I could blame Columbia University College of Physicians and Surgeons, I’d have canned Haig for the article as well.
Modern medicine is very complex. It is virtually impossible for your physician to know everything about every disease. Actually that’s not true- it is impossible not virtually impossible. Physicians need to stop being annoyed. They need to accept that the knowledge gained in their training and held in secret is readily available to all- for free. Good physicians will learn to assess internet sources and allow their knowledeg to grow. Alternatively a skilled physician will disabuse patients of disinformation. Haig appears to prefer his patients obedient, unquestioning, and servile.
Dr. Rahul K. Parikh agrees with me. He assess Haig’s patently unprofessional comments and behavior somewhat more charitably than I do. The lay press likewise agrees with me. I believe that guys like Haig have no business in medicine. Any physician who is too busy or too insecure to respond effectively to legitimate questions need another profession.
Regardless of the internet, the information disparity in medicine prohibits a true free market. Guys like Haig prey on the ingorant and unsuspecting. They are exactly the reason that patients feel abused or misled (the same feelings that frequently generate litigation thereby driving up cost and limiting access to healthcare). They perpetuate a cloistered, arcane system that forces patients to be little more than livestock used to generate revenue.
If your physician can’t or won’t answer your questions you need a new physician. If your physician seems to indicate that “he’s the doctor and you’re the patient” you need a new physician. If your physician perpetuates the kind of paternalistic nonsense that Haig seems to yearn for then you need a new physician.
It’s your health. You can’t turn it over to guys like Haig.
I truly believe that most physicians are honest, decent people. (I also believe that most lawyers are honest decent people-but more people argue with me on the latter.) There are, however some physicians who are simply criminals.
Here in Texas, and across the south, lawsuits involving silicosis and asbestosis seemed to be appearing with alarming and increasing frequency. Judge Janis Jack from the Federal District Court in Corpus Christi thought this sounded wrong when the resulting mass tort case ended up in her court. Her opinion, nearly 250 pages is a scathing rebuke of Dr. Jay Segarra (Dr. Segarra has been excoriated elsewhere by lawyers as well).
Worse than the millions of dollars Segarra bilked people out of is the irreparable loss of trust. There is also the incalculable angony and expense imposed on his victims associated with additional, unnecessary testing.
Judge Jack, quite appropriately, has handed down a decision that will be a step towards improving quality of legal services and mass torts. The price may be a small reduction in access to the court. The other side though will be an improvement in the quality of healthcare as well as legal care.
Judge Jack is one of the few people actually watching out for your health.
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