Tuesday, August 30, 2005

Grand Rounds 49

I am quite the slouch! I forgot to post that Grand Rounds is up at HealthyConcerns.com --- it's always worth the time to peruse the best of the medical blogosphere!

Buckle Up, Part II

The images I will show in this post are ones that are going to be seen very rarely --- because they indicate a fatal process, and the patient usually will not survive the accident or trip to the hospital. However, they illustrate very well the importance of, you guessed it, seatbelts.

This accident occurred some time ago; this was an older lady who was an unbelted driver of a vehicle involved in a head-on collision. On arrival to the ED, she had obvious chest trauma, with rib fractures and a widened mediastinum seen on chest x-ray. In blunt chest trauma, this sign is worrisome for aortic trauma. She was taken to the CT scanner, where we saw this on the upper thoracic cuts:

There is blood around the aorta and a breech in the posterolateral wall of the aorta. This is where the dissection has started and there is free flow of blood outside the vessel. This is also where the flap of the dissection starts -- where a portion of the wall of the vessel has torn, blocking off normal flow through the lumen of the aorta, which worsens on lower cuts.

In this cut, the aorta can be seen behind the heart with with contrast filling only the anterior half of the vessel -- the dissection is larger here. As well, there is contrast material in the heart (as expected) but also outside the heart in the pericardium (definitely not expected). This once again is due to the aortic disruption causing blood to extravasate, here progressing back along the aorta and into the sac surrounding the heart. This will very rapidly cause the heart to become so constricted that it cannot allow blood to return from the vena cava and pump it back out again --pericardial tamponade.

This is a cut from the area of the diaphragmatic hiatus. The full effects of the dissection can be seen, with very little contrast seen in the lumen of the aorta. The right lobe of the liver is affected, with complete absence of blood flow seen; the left lobe is being perfused by a tiny branch off the nearly occluded celiac artery.

This lady was basically expiring in the CT scanner; it is extremely unusual that she survived to make it to the hospital, as the majority of these patients are dead at the scene. It may have been the case that she had a delayed progression of her dissection initially. At this stage, this is a non-survivable, non-treatable injury unless the patient is extremely stable -- which she was not. By the time the few minutes had passed to get these scans, she was in extremis.

Traumatic aortic rupture can occur with both frontal (head-on) and lateral (T-bone) auto crashes. There are some patients who suffer aortic tears who do not have such a catastrophic outcome, however; their ruptures are contained, and the dissection does not cause occlusion of the major intraabdominal vessels. In the past, they were treated with emergent operation, but complications were frequent as they generally had a variety of associated injuries. Today, in general, a delayed repair is recommended.

Tuesday, August 23, 2005

Grand Rounds

Dr. Kevin is quite the busy guy -- now running two blogs as well as his practice! Check out Grand Rounds at his site Straightfromthedoc.

Monday, August 22, 2005

Merck/Vioxx Redux

I suspect that many (of the few) who read this blog are very familiar with Kevin, M.D.'s site, which is a good compendium of medical news. A frequent commenter at that site is Curious JD, who offers his legal perspective when there is a discussion of a medicolegal topic at Kevin's site. He also had a few questions for me in regards to my recent post about the Merck/Vioxx verdict. Rather than addressing those questions in the comments, I would like to flesh out my concerns and answers in this post.

CJD: How much of the trial testimony or admitted exhibits have you reviewed in coming to the conclusion the verdict was faulty?

Actually, none, as those are not readily available to me. However, as a matter of principle, I believe that the premise of holding a corporation liable for a person's death is untenable when:

  1. The examining pathologist at the patient's post mortem stated that he had coronary artery disease, a much more likely source for his death
  2. The pathologist blamed that death on an arrhythmia caused a blood clot in a coronary artery....which she did not find at autopsy (you sort of need proof of a "smoking gun" if you claim there is one). None of the trials looking at Vioxx demonstrated an increased risk of arrhythmia, and the increased heart attack risks showed up only after the patient was on the drug for a minimum of 18 months (this gentleman had been on it 8 months).
  3. There is no evidence that Merck put out Vioxx to intentionally harm patients
  4. There are other, similar medications on the market which have the same profile and side effects as Vioxx, which were developed in response to a perceived need, and which work well to address that need ---- and which were approved by the FDA
  5. Medicine is a fluid science; we find things out every year which seem to contradict what we believed to be true last year. I'd recommend that you read about the evolution of the ACLS protocol --- which has changed so much that it is hardly recognizable to those who first learned it 10 years ago. And, by the way, things that were once in vogue, and then were banished from the protocol, are back in vogue again. This is true in all aspects of medicine.
CJD: By the way, that "outrageous sum" (which will never be paid), represents about 1% of Merck's 2004 revenues. Just to add a little perspective.

What difference does that make? What if it was .001% of Merck's 2004 revenues? This is not "perspective," it is rationalization for taking money away from a corporation to suit the jury's perception that Merck "needs to be punished."

CJD: By the way, do you ever think the tort system is "insane" when the defendant wins? Or is it only when the plaintiff wins?

I think the tort system is insane when:
  1. The "tort" involved is a fabrication --- particularly when it is based on junk science. I'd recommend you review the studies about breast implants.
  2. The amount of money "awarded" is totally out of proportion to reality --- as in this case. What, exactly, makes this poor gentleman's death worth $450,000 in economic damages for lost pay and $24 million for mental anguish and loss of companionship, excluding the $229 million in punitive damages.
  3. The only defendant in the suit is the one with "biggest pockets." Why, for example, was this man's physician not sued? Or his insurance company (which I am sure had a pharmacy schedule mandating which COX-2 inhibitor he was allowed to receive)?
  4. The suit is a class action, designed to ensure that a large amount of money
  5. The attorney makes anything other than a flat fee. Yep, that's right, I think it's high time we established a legal counterpart to Medicare. After all, we are told by trial attorneys that anything that acts to inhibit unfettered access to suing is just flat out unconstitutional. So, let's set up "LegalCare," and ensure that everyone has the same access to attorneys, to sue whomever they please, all for a government-determined fee.
In all honesty, I fear that there is a disconnect between reality and fantasy these days in our courts. We need to grow up, and realize that sometimes, shit happens, and it's nobody's fault. I'm not a lawyer, but these guys are -- read what they have to say, as I suspect they say it in a less emotional, better to understand way.

Saturday, August 20, 2005


For the man who has eveything, or just needs a new grill. Zero to sixty burgers in less than 8 seconds!

Friday, August 19, 2005

Un. Be. Lievable

This is, quite frankly, despicable and indicative of the problem we have in this country with a tort system that has no restraint. Here's the kicker:

Unlike many other pending lawsuits involving obvious heart attacks, the Ernst case centered on an autopsy that attributed his death to an arrhythmia secondary to clogged arteries. That autopsy — and the coroner who performed it — proved critical to the trial's outcome.

Merck pointed to the autopsy as proof that Vioxx could not have caused the death of Ernst, who ran marathons and taught aerobics.

However, Dr. Maria Araneta, the pathologist who performed Ernst's autopsy, testified for Ernst that a blood clot that she couldn't find probably caused a heart attack that triggered Ernst's arrhythmia. She also said the heart attack killed Ernst too quickly for his heart to show damage.

While Araneta couldn't say definitively that he had a blood clot and heart attack, she insisted they were the likely culprits in triggering an arrhythmia, which she said wouldn't happen on its own.

And her evidence was......? Can't wait to see the feeding frenzy that follows this decision. If we are to remain a leader in the world, whether in medicine, technology, or tiddlywinks, some sanity must be restored to the tort system. Quite frankly, I am embarrassed to say that I was born in the state that produced this decision.
{And yes, I know, the article points out that state law caps the award amount, so Merck won't be faced with paying the outrageous sum --- the despicable part is that basically, there's no proof that this man died as a result of taking Vioxx, and no proof that Merck did anything wrong to this man. Sort of echoes the whole breast implant brouhaha.}

Tuesday, August 16, 2005

And now for something completely different

One of my all-time favorite comedians, John Cleese, will soon be faced with "something completely different" -- he's due to have a colectomy for diverticular disease. One wonders about the potential banter in that operating room! We rather frequently have battling "Holy Grail" quotefests in our OR, and I must admit that I am most partial to Cleese's French insult sequences.

"You don't frighten us, English pig-dogs! Go and boil your bottoms, sons of a silly person. I blow my nose on you, so-called Arthur king, you and your silly English Knn...niggets."
"I don't want to talk to you no more, you empty-headed animal food trough wiper. I fart in your general direction. Your mother was a hamster and your father smelt of elderberries."
"No chance, English bed-wetting types. I burst my pimples at you, and call your door-opening request a silly thing. You tiny-brained wipers of other people's bottoms!"

Will this be the view he sees as he drifts off to sleep?

Hope he does well.

Grand Rounds 47

Grand Rounds is up, and you know it has got to be better than reading the latest political blogs. Head over to Circadiana and get your fill at the medicine cabinet.

Monday, August 15, 2005

EMTALA, ED Call, and Medicare

I have written previously about the difficulties hospitals and physicians are having with providing on-call coverage. Simply put, many specialists (and non-specialists) view ED coverage as a poorly reimbursed burden, laden with a worrisome risk for malpractice exposure. On the other hand, hospitals need to have specialty coverage commensurate with the services they provide for elective patients -- this was codified by the Emergency Medical Treatment and Labor Act (EMTALA), passed in 1986.

Given today's falling reimbursement (particularly from Medicare, but also all insurers), rising malpractice rates, and increasing numbers of uninsured, some physicians are trying to opt out of or decrease their ED call coverage. Presently, many facilities are starting to pay for ED specialist coverage, or are considering employment agreements. While those responses take dollars out of the system, they do have the advantage of ensuring the hospital is EMTALA-compliant. Some hospital associations, however, have tried to take a different approach -- trying to get the Centers for Medicare and Medicaid Services (CMS) to link on-call requirements to Medicare participation. A federal advisory panel that meets twice per year to review EMTALA issues recently voted against that proposition, albeit by a narrow margin. Full details can be read here in the article entitled "Panel Says 'No' to On-Call/Medicare Link."

If such a link were enacted, however, "physicians would quit Medicare in droves, " Dr. Bayer told this newspaper. Participating in Medicare means "you abide by the rules and have to accept the payments, but it has never been linked to anything like this before."
"We've had testimony, we've had studies, and we've had surveys on both sides of this issue. Cultural changes are taking place in medicine right now that don't bode well for emergency medicine," Dr. Nepola said. "Young physicians are moving as quickly as they can to study fields that do not require emergency work at all. They are moving towards boutique practices, which I abhor."
I can easily see certain fields where physicians would simply say "don't throw me in that briar patch! OK, I won't take ED call, and I won't see any Medicare patients either! I'll just line up all of those knee scopes (or lumbar diskectomies, or skin lesion biopsies, or routine physicals......) and make sure the poor ED physician can never interrupt my elective schedule again!"

I admit I have mixed feelings about all of this. Clearly, mandating ED call coverage to allow participation in Medicare is a very poor solution, and would never work. By the same token, patients with emergent problems need access to specialists; we also have a responsibility to care for those patients when we are on call. As with everything else in our society, the true solution can be found in the free market ---- if the majority of patients seen in the ED provided physicians with enough reimbursement to make coverage financially viable, more physicians would be interested in providing that service. However, these days, the free market isn't allowed to be applied in medicine, and that just ain't gonna happen!

Tuesday, August 09, 2005

Medical, and Legal, Fraud

How did I miss this? What a great story, which didn't seem to get picked up by the national news media:

Doctors' silicosis records sought

"Federal grand jury subpoenas diagnoses called "manufactured"

Gee, do you think now there will be some backbone to go after the asbestos and silicone breast implant lawsuits now as well? Tip of the hat to Lucianne.

UPDATE 8/12: It appears that a efw in Congress are beginning to notice this type of fraud:
House Republicans Joe Barton and Ed Whitfield, who last week opened a probe into the nation's asbestos and silicosis claims. Their decision to investigate the people responsible for recruiting and falsely diagnosing tens of thousands of plaintiffs is a major step toward exposing this fraud.
Woo-hoo! Hopefully this is a step in the right direction! Hat tip to Rodger Schultz

Grand Rounds

The 46th edition of Grand Rounds is being hosted by Doc Emer in the South Pacific. It's an excellent collection of medical blogging -- check it out!

Thursday, August 04, 2005

Seatbelts and Trauma

This is an interesting case my partner had recently. A young man was traveling in the back seat of his family's large SUV (gross weight 9200 pounds) when it was struck head on at about 70 mph by a much smaller vehicle. In a stunning display of the laws of physics, the SUV flattened the smaller car, as well as its passenger. All of the family members in the SUV were wearing their seatbelts, except for this young man, who was wearing only the lap belt portion, slinging the shoulder harness behind him. He arrived here with a classic "seat belt sign" on the abdominal wall, and had this impressive CT scan (click on pictures for a larger view):

The arrow on the right side of the image points to a normal abdominal wall contour, with normal musculature. On the left side, the circle shows complete loss of the abdominal wall, with bowel laying up against the skin.

A few cuts lower, the edges of the muscle can be seen (arrows). The whole abdominal wall musculature had been divided in two, indicative of massive force.

In this scenario, a whole host of other injuries can be found, including a ruptured diaphragm, small and large bowel perforation or devascularization, spinal fracture, liver fracture, and pancreatic injury. Upon exploration, he was found to have a completely disrupted abdominal wall, but no solid organ injury. The right diaphragm had been torn fairly significantly and had to be reattached to the ribs; most of the liver attachments had been ripped as well, but fortunately there was no liver injury. He had one unstable spinal fracture which was stabilized the following day.

This case illustrates the forces that are applied to torsos in auto accidents, as well as the reason that modern seatbelts were invented. Without a seatbelt, this young man would be yet another auto crash fatality statistic. With half a seatbelt, he suffered significant injuries. With a full seatbelt, he may have been less severely injured.

Buckle up.