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Outcomes: Getting to the patient’s bottom line
It’s easy to get so caught up in our day-to-day routines. At the hospital, we’re meeting core measures, documenting correctly, following clinical guidelines, and simply striving to stay up to date with the literature. At home, there are soccer games, recitals, and homework – and some rare personal time. We often shift to automatic pilot in a desperate attempt to balance the seemingly never-ending demands.
But does the very nature of our hectic lives sometimes prevent us from seeing the bigger picture, especially when it comes to the things that are really important to our patients? Yes, we know what lab values automatically trigger an order for a statin, and what ejection fraction on the echocardiogram warrants an ACE inhibitor, but how often do we really take the time to find out about the outcomes that are important to our patients? Sometimes they aren’t the evidence-based clinical outcomes we are trying to reproduce with our treatments.
For many patients, the desired outcome is to feel better, plain and simple. All the fancy lingo and drugs with unpronounceable names and unintelligible indications can be overwhelming. They make some patients shut down, and ultimately shut us out. We may not even realize it until our patients are readmitted as a result of noncompliance with our well-thought-out treatment plans.
There are our male patients who rarely take their blood pressure medicine because of the side effect of sexual dysfunction. And then there are those patients who don’t take their medications or see their doctors regularly because they just cannot afford it. While they seem to be in agreement with the follow-up plan for medical visits and testing, patients may be ashamed to admit they are uninsured or underinsured. They know they will never be adherent because they just cannot afford the costs of our treatment plan.
Instead of getting frustrated with our noncompliant patients, we could better serve them by getting more personal – gaining their trust as we carefully and respectfully uncover the layers of the limitations they face and the outcomes that matter to them. We need to aim to be viewed as our patients’ caring advocates and not just aloof professionals with no clue about their daily struggles.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.
It’s easy to get so caught up in our day-to-day routines. At the hospital, we’re meeting core measures, documenting correctly, following clinical guidelines, and simply striving to stay up to date with the literature. At home, there are soccer games, recitals, and homework – and some rare personal time. We often shift to automatic pilot in a desperate attempt to balance the seemingly never-ending demands.
But does the very nature of our hectic lives sometimes prevent us from seeing the bigger picture, especially when it comes to the things that are really important to our patients? Yes, we know what lab values automatically trigger an order for a statin, and what ejection fraction on the echocardiogram warrants an ACE inhibitor, but how often do we really take the time to find out about the outcomes that are important to our patients? Sometimes they aren’t the evidence-based clinical outcomes we are trying to reproduce with our treatments.
For many patients, the desired outcome is to feel better, plain and simple. All the fancy lingo and drugs with unpronounceable names and unintelligible indications can be overwhelming. They make some patients shut down, and ultimately shut us out. We may not even realize it until our patients are readmitted as a result of noncompliance with our well-thought-out treatment plans.
There are our male patients who rarely take their blood pressure medicine because of the side effect of sexual dysfunction. And then there are those patients who don’t take their medications or see their doctors regularly because they just cannot afford it. While they seem to be in agreement with the follow-up plan for medical visits and testing, patients may be ashamed to admit they are uninsured or underinsured. They know they will never be adherent because they just cannot afford the costs of our treatment plan.
Instead of getting frustrated with our noncompliant patients, we could better serve them by getting more personal – gaining their trust as we carefully and respectfully uncover the layers of the limitations they face and the outcomes that matter to them. We need to aim to be viewed as our patients’ caring advocates and not just aloof professionals with no clue about their daily struggles.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.
It’s easy to get so caught up in our day-to-day routines. At the hospital, we’re meeting core measures, documenting correctly, following clinical guidelines, and simply striving to stay up to date with the literature. At home, there are soccer games, recitals, and homework – and some rare personal time. We often shift to automatic pilot in a desperate attempt to balance the seemingly never-ending demands.
But does the very nature of our hectic lives sometimes prevent us from seeing the bigger picture, especially when it comes to the things that are really important to our patients? Yes, we know what lab values automatically trigger an order for a statin, and what ejection fraction on the echocardiogram warrants an ACE inhibitor, but how often do we really take the time to find out about the outcomes that are important to our patients? Sometimes they aren’t the evidence-based clinical outcomes we are trying to reproduce with our treatments.
For many patients, the desired outcome is to feel better, plain and simple. All the fancy lingo and drugs with unpronounceable names and unintelligible indications can be overwhelming. They make some patients shut down, and ultimately shut us out. We may not even realize it until our patients are readmitted as a result of noncompliance with our well-thought-out treatment plans.
There are our male patients who rarely take their blood pressure medicine because of the side effect of sexual dysfunction. And then there are those patients who don’t take their medications or see their doctors regularly because they just cannot afford it. While they seem to be in agreement with the follow-up plan for medical visits and testing, patients may be ashamed to admit they are uninsured or underinsured. They know they will never be adherent because they just cannot afford the costs of our treatment plan.
Instead of getting frustrated with our noncompliant patients, we could better serve them by getting more personal – gaining their trust as we carefully and respectfully uncover the layers of the limitations they face and the outcomes that matter to them. We need to aim to be viewed as our patients’ caring advocates and not just aloof professionals with no clue about their daily struggles.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.
When your diagnosis is questioned
When patients question your diagnosis, how do you react?
As physicians, we take great pride in our ability to diagnose and treat disease, and as hospitalists, our patients are sicker, so we need to make the right diagnosis and make it fast. A diagnostic delay of even a few days can sometimes cost a patient his life.
So when the patient or a family member disagrees with your diagnosis – especially when they have no remote understanding of the condition – it can be easy to dismiss their concerns. And then there are the times when you’ve missed something and they are right.
I will never forget a 60-year-old male patient I encountered early in my career as a hospitalist. He had presented with diffuse abdominal pain which later localized to both lower quadrants, diarrhea, and CT scan evidence of gastroenteritis. Multiple doctors who saw the patient before me all had the same diagnosis, a simple case of gastroenteritis. By day 2, he was afebrile, had a normal white blood cell count, was eating, and was ambulating down the hallway with his large family, seemingly in no distress.
He related that he still had abdominal pain, but felt comfortable with his diagnosis and was amenable to being discharged to follow-up with the gastroenterologist who had consulted on him during his stay in the hospital. His niece, on the other hand, was not happy with the diagnosis. The look on her face was intense, not disrespectful, as she related her conviction that her uncle had something more going on than a bout of gastroenteritis. She knew her uncle far better than I did, and his pain was concerning to her.
So I went back to the drawing board to make sure nothing had been missed, and there, hidden in plain sight, was a vital piece of information that we had all overlooked. The CT scan report that showed signs consistent with gastroenteritis made no mention whatsoever of his appendix.
Not satisfied with simply having another radiologist read the film, I insisted that a surgeon see the patient. To the surgeon’s great surprise, and mine, he found evidence of appendicitis. By 10 a.m. the next morning, the patient was in the OR having a now-perforated appendix removed. After numerous apologies to the family and patient, he was discharged home on postop day 2, doing well.
That very scary near miss taught me a valuable lesson: Sometimes the gut instinct of patients and their family members is just as accurate as the gut instinct of a physician, and we need to fully respect their input, whether or not we agree with them.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.
When patients question your diagnosis, how do you react?
As physicians, we take great pride in our ability to diagnose and treat disease, and as hospitalists, our patients are sicker, so we need to make the right diagnosis and make it fast. A diagnostic delay of even a few days can sometimes cost a patient his life.
So when the patient or a family member disagrees with your diagnosis – especially when they have no remote understanding of the condition – it can be easy to dismiss their concerns. And then there are the times when you’ve missed something and they are right.
I will never forget a 60-year-old male patient I encountered early in my career as a hospitalist. He had presented with diffuse abdominal pain which later localized to both lower quadrants, diarrhea, and CT scan evidence of gastroenteritis. Multiple doctors who saw the patient before me all had the same diagnosis, a simple case of gastroenteritis. By day 2, he was afebrile, had a normal white blood cell count, was eating, and was ambulating down the hallway with his large family, seemingly in no distress.
He related that he still had abdominal pain, but felt comfortable with his diagnosis and was amenable to being discharged to follow-up with the gastroenterologist who had consulted on him during his stay in the hospital. His niece, on the other hand, was not happy with the diagnosis. The look on her face was intense, not disrespectful, as she related her conviction that her uncle had something more going on than a bout of gastroenteritis. She knew her uncle far better than I did, and his pain was concerning to her.
So I went back to the drawing board to make sure nothing had been missed, and there, hidden in plain sight, was a vital piece of information that we had all overlooked. The CT scan report that showed signs consistent with gastroenteritis made no mention whatsoever of his appendix.
Not satisfied with simply having another radiologist read the film, I insisted that a surgeon see the patient. To the surgeon’s great surprise, and mine, he found evidence of appendicitis. By 10 a.m. the next morning, the patient was in the OR having a now-perforated appendix removed. After numerous apologies to the family and patient, he was discharged home on postop day 2, doing well.
That very scary near miss taught me a valuable lesson: Sometimes the gut instinct of patients and their family members is just as accurate as the gut instinct of a physician, and we need to fully respect their input, whether or not we agree with them.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.
When patients question your diagnosis, how do you react?
As physicians, we take great pride in our ability to diagnose and treat disease, and as hospitalists, our patients are sicker, so we need to make the right diagnosis and make it fast. A diagnostic delay of even a few days can sometimes cost a patient his life.
So when the patient or a family member disagrees with your diagnosis – especially when they have no remote understanding of the condition – it can be easy to dismiss their concerns. And then there are the times when you’ve missed something and they are right.
I will never forget a 60-year-old male patient I encountered early in my career as a hospitalist. He had presented with diffuse abdominal pain which later localized to both lower quadrants, diarrhea, and CT scan evidence of gastroenteritis. Multiple doctors who saw the patient before me all had the same diagnosis, a simple case of gastroenteritis. By day 2, he was afebrile, had a normal white blood cell count, was eating, and was ambulating down the hallway with his large family, seemingly in no distress.
He related that he still had abdominal pain, but felt comfortable with his diagnosis and was amenable to being discharged to follow-up with the gastroenterologist who had consulted on him during his stay in the hospital. His niece, on the other hand, was not happy with the diagnosis. The look on her face was intense, not disrespectful, as she related her conviction that her uncle had something more going on than a bout of gastroenteritis. She knew her uncle far better than I did, and his pain was concerning to her.
So I went back to the drawing board to make sure nothing had been missed, and there, hidden in plain sight, was a vital piece of information that we had all overlooked. The CT scan report that showed signs consistent with gastroenteritis made no mention whatsoever of his appendix.
Not satisfied with simply having another radiologist read the film, I insisted that a surgeon see the patient. To the surgeon’s great surprise, and mine, he found evidence of appendicitis. By 10 a.m. the next morning, the patient was in the OR having a now-perforated appendix removed. After numerous apologies to the family and patient, he was discharged home on postop day 2, doing well.
That very scary near miss taught me a valuable lesson: Sometimes the gut instinct of patients and their family members is just as accurate as the gut instinct of a physician, and we need to fully respect their input, whether or not we agree with them.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.
DEA Schedule Change Inhibits Practice and Patient Care
Note from NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP: Recently, the authors of this column and I started discussing the decision by the Drug Enforcement Administration (DEA) to reschedule hydrocodone and the resulting barriers to care. By the end of the conversation, it was evident that my colleagues needed to “get the word out” to our readers—so I afforded them this opportunity to do so.
On October 6, 2014, hydrocodone combination products were reclassified from Schedule III to Schedule II of the Controlled Substances Act, per a final ruling issued by the DEA’s Office of Diversion Control. The DEA’s ruling was the result of an evaluation of scientific and medical evidence supplied by multiple agencies, as well as considerations related to the FDA Safety and Innovation Act of 2012.1 The rationale for rescheduling hydrocodone preparations was based on evidence of high potential for abuse, high rates of dependency, and epidemic levels of drug diversion related to these products.
Our purpose in this editorial is not to debate the DEA’s decision to reschedule hydrocodone preparations but rather to demonstrate that all policy changes have consequences. In this case, these include substantial limitations on the ability of NPs in several states to adequately manage acute and chronic pain for their patients. As a result, NPs may be prevented from delivering comprehensive care to patients with certain conditions. (We are aware that our PA colleagues may be similarly affected by this ruling but will restrict our commentary to NPs, as we are most familiar with our profession’s circumstances.)
Each state grants specific prescriptive privileges to advanced practice registered nurses (APRNs), resulting in wide variation across the country. Therefore, the effect of this ruling on patients’ access to care and providers’ ability to treat certain conditions differs by state. The states in which APRNs have prescriptive privileges for Schedule III but not Schedule II medications—those most impacted by this rule change—include Arkansas, Georgia, Missouri, Nebraska, Oklahoma, South Carolina, Texas, and West Virginia.2 Prior to the effective date of this ruling, NPs in these states had hydrocodone and codeine preparations, as well as the nonnarcotic tramadol, in their armamentaria to treat pain.
The DEA ruling—coupled with restrictive state regulations—reduces the options for pain management in these states. The only other Schedule III narcotic treatment options are codeine preparations; for patients with codeine sensitivities or allergies, NPs are now unable to adequately manage acute or chronic pain. Besides inconvenience, this change results in additional costs, since patients will also need to be assessed by a provider with Schedule II prescriptive privileges if they hope to achieve adequate pain management. This is particularly burdensome in underserved or rural populations, which many of the affected states have.
In response to this (presumably) unintended consequence, legislatures need to consider the impact this ruling will have on patient care and move to modernize prescriptive authority for APRNs, especially in the most affected states. The Future of Nursing report3 from the Institute of Medicine (IOM) recommends that APRNs’ scope of practice be reformed to conform with the model rules and regulations established by the National Council of State Boards of Nursing (NCSBN). The NCSBN’s consensus model report supports full scope of practice for all APRNs, as well as collaboration among all health care disciplines as a professional norm, instead of the current restrictive practices.4
Continued on next page >>
Historically, APRNs have struggled to gain total support from state legislators in the quest for full practice authority, including prescriptive privileges. Our professional organizations, with support from the IOM, the National Governors Association, and the Federal Trade Commission, must be ready to provide accurate data on safety and outcomes to state and federal legislators. This evidence would support efforts to modernize NP scope of practice acts, including prescribing regulations, that are currently outdated and prevent APRNs from providing optimal care.5
This year (2015) marks the 50th anniversary of the NP role. Thus, it is the proper time for state legislatures to recognize and support the role of the NP in the delivery of comprehensive, cost-effective health care in the United States. With millions of previously uninsured Americans seeking primary care and the increasing shortage of primary care physicians, NPs are part of the answer to the problem of access to acute and chronic care in both urban and rural communities. With NPs available to close this gap, it is imperative that both state and federal legislatures support initiatives that will eliminate barriers to care and promote legislation that offers full scope of practice to NPs.
We welcome your feedback on this topic. Please send your comments to NPEditor@frontline medcom.com.
REFERENCES
1. Drug Enforcement Administration. Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II (document no: 2014-19922). Federal Register. https://federalregister.gov/a/2014-19922. Accessed February 13, 2015.
2. Drug Enforcement Administration Office of Diversion. Mid-level practitioners authorization by state. www.deadiversion.usdoj.gov/drugreg/practioners. Accessed February 13, 2015.
3. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
4. National Council of State Boards of Nursing. The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education (2008). www.ncsbn.org/Consen sus_Model_for_APRN_Regulation_July_2008.pdf. Accessed February 13, 2015.
5. National Council of State Boards of Nursing. Changes In Healthcare Professions’ Scope of Practice: Legislative Considerations (2009). www.ncsbn.org/ScopeofPractice_09.pdf. Accessed February 13, 2015.
Note from NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP: Recently, the authors of this column and I started discussing the decision by the Drug Enforcement Administration (DEA) to reschedule hydrocodone and the resulting barriers to care. By the end of the conversation, it was evident that my colleagues needed to “get the word out” to our readers—so I afforded them this opportunity to do so.
On October 6, 2014, hydrocodone combination products were reclassified from Schedule III to Schedule II of the Controlled Substances Act, per a final ruling issued by the DEA’s Office of Diversion Control. The DEA’s ruling was the result of an evaluation of scientific and medical evidence supplied by multiple agencies, as well as considerations related to the FDA Safety and Innovation Act of 2012.1 The rationale for rescheduling hydrocodone preparations was based on evidence of high potential for abuse, high rates of dependency, and epidemic levels of drug diversion related to these products.
Our purpose in this editorial is not to debate the DEA’s decision to reschedule hydrocodone preparations but rather to demonstrate that all policy changes have consequences. In this case, these include substantial limitations on the ability of NPs in several states to adequately manage acute and chronic pain for their patients. As a result, NPs may be prevented from delivering comprehensive care to patients with certain conditions. (We are aware that our PA colleagues may be similarly affected by this ruling but will restrict our commentary to NPs, as we are most familiar with our profession’s circumstances.)
Each state grants specific prescriptive privileges to advanced practice registered nurses (APRNs), resulting in wide variation across the country. Therefore, the effect of this ruling on patients’ access to care and providers’ ability to treat certain conditions differs by state. The states in which APRNs have prescriptive privileges for Schedule III but not Schedule II medications—those most impacted by this rule change—include Arkansas, Georgia, Missouri, Nebraska, Oklahoma, South Carolina, Texas, and West Virginia.2 Prior to the effective date of this ruling, NPs in these states had hydrocodone and codeine preparations, as well as the nonnarcotic tramadol, in their armamentaria to treat pain.
The DEA ruling—coupled with restrictive state regulations—reduces the options for pain management in these states. The only other Schedule III narcotic treatment options are codeine preparations; for patients with codeine sensitivities or allergies, NPs are now unable to adequately manage acute or chronic pain. Besides inconvenience, this change results in additional costs, since patients will also need to be assessed by a provider with Schedule II prescriptive privileges if they hope to achieve adequate pain management. This is particularly burdensome in underserved or rural populations, which many of the affected states have.
In response to this (presumably) unintended consequence, legislatures need to consider the impact this ruling will have on patient care and move to modernize prescriptive authority for APRNs, especially in the most affected states. The Future of Nursing report3 from the Institute of Medicine (IOM) recommends that APRNs’ scope of practice be reformed to conform with the model rules and regulations established by the National Council of State Boards of Nursing (NCSBN). The NCSBN’s consensus model report supports full scope of practice for all APRNs, as well as collaboration among all health care disciplines as a professional norm, instead of the current restrictive practices.4
Continued on next page >>
Historically, APRNs have struggled to gain total support from state legislators in the quest for full practice authority, including prescriptive privileges. Our professional organizations, with support from the IOM, the National Governors Association, and the Federal Trade Commission, must be ready to provide accurate data on safety and outcomes to state and federal legislators. This evidence would support efforts to modernize NP scope of practice acts, including prescribing regulations, that are currently outdated and prevent APRNs from providing optimal care.5
This year (2015) marks the 50th anniversary of the NP role. Thus, it is the proper time for state legislatures to recognize and support the role of the NP in the delivery of comprehensive, cost-effective health care in the United States. With millions of previously uninsured Americans seeking primary care and the increasing shortage of primary care physicians, NPs are part of the answer to the problem of access to acute and chronic care in both urban and rural communities. With NPs available to close this gap, it is imperative that both state and federal legislatures support initiatives that will eliminate barriers to care and promote legislation that offers full scope of practice to NPs.
We welcome your feedback on this topic. Please send your comments to NPEditor@frontline medcom.com.
REFERENCES
1. Drug Enforcement Administration. Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II (document no: 2014-19922). Federal Register. https://federalregister.gov/a/2014-19922. Accessed February 13, 2015.
2. Drug Enforcement Administration Office of Diversion. Mid-level practitioners authorization by state. www.deadiversion.usdoj.gov/drugreg/practioners. Accessed February 13, 2015.
3. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
4. National Council of State Boards of Nursing. The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education (2008). www.ncsbn.org/Consen sus_Model_for_APRN_Regulation_July_2008.pdf. Accessed February 13, 2015.
5. National Council of State Boards of Nursing. Changes In Healthcare Professions’ Scope of Practice: Legislative Considerations (2009). www.ncsbn.org/ScopeofPractice_09.pdf. Accessed February 13, 2015.
Note from NP Editor-in-Chief Marie-Eileen Onieal, PhD, CPNP, FAANP: Recently, the authors of this column and I started discussing the decision by the Drug Enforcement Administration (DEA) to reschedule hydrocodone and the resulting barriers to care. By the end of the conversation, it was evident that my colleagues needed to “get the word out” to our readers—so I afforded them this opportunity to do so.
On October 6, 2014, hydrocodone combination products were reclassified from Schedule III to Schedule II of the Controlled Substances Act, per a final ruling issued by the DEA’s Office of Diversion Control. The DEA’s ruling was the result of an evaluation of scientific and medical evidence supplied by multiple agencies, as well as considerations related to the FDA Safety and Innovation Act of 2012.1 The rationale for rescheduling hydrocodone preparations was based on evidence of high potential for abuse, high rates of dependency, and epidemic levels of drug diversion related to these products.
Our purpose in this editorial is not to debate the DEA’s decision to reschedule hydrocodone preparations but rather to demonstrate that all policy changes have consequences. In this case, these include substantial limitations on the ability of NPs in several states to adequately manage acute and chronic pain for their patients. As a result, NPs may be prevented from delivering comprehensive care to patients with certain conditions. (We are aware that our PA colleagues may be similarly affected by this ruling but will restrict our commentary to NPs, as we are most familiar with our profession’s circumstances.)
Each state grants specific prescriptive privileges to advanced practice registered nurses (APRNs), resulting in wide variation across the country. Therefore, the effect of this ruling on patients’ access to care and providers’ ability to treat certain conditions differs by state. The states in which APRNs have prescriptive privileges for Schedule III but not Schedule II medications—those most impacted by this rule change—include Arkansas, Georgia, Missouri, Nebraska, Oklahoma, South Carolina, Texas, and West Virginia.2 Prior to the effective date of this ruling, NPs in these states had hydrocodone and codeine preparations, as well as the nonnarcotic tramadol, in their armamentaria to treat pain.
The DEA ruling—coupled with restrictive state regulations—reduces the options for pain management in these states. The only other Schedule III narcotic treatment options are codeine preparations; for patients with codeine sensitivities or allergies, NPs are now unable to adequately manage acute or chronic pain. Besides inconvenience, this change results in additional costs, since patients will also need to be assessed by a provider with Schedule II prescriptive privileges if they hope to achieve adequate pain management. This is particularly burdensome in underserved or rural populations, which many of the affected states have.
In response to this (presumably) unintended consequence, legislatures need to consider the impact this ruling will have on patient care and move to modernize prescriptive authority for APRNs, especially in the most affected states. The Future of Nursing report3 from the Institute of Medicine (IOM) recommends that APRNs’ scope of practice be reformed to conform with the model rules and regulations established by the National Council of State Boards of Nursing (NCSBN). The NCSBN’s consensus model report supports full scope of practice for all APRNs, as well as collaboration among all health care disciplines as a professional norm, instead of the current restrictive practices.4
Continued on next page >>
Historically, APRNs have struggled to gain total support from state legislators in the quest for full practice authority, including prescriptive privileges. Our professional organizations, with support from the IOM, the National Governors Association, and the Federal Trade Commission, must be ready to provide accurate data on safety and outcomes to state and federal legislators. This evidence would support efforts to modernize NP scope of practice acts, including prescribing regulations, that are currently outdated and prevent APRNs from providing optimal care.5
This year (2015) marks the 50th anniversary of the NP role. Thus, it is the proper time for state legislatures to recognize and support the role of the NP in the delivery of comprehensive, cost-effective health care in the United States. With millions of previously uninsured Americans seeking primary care and the increasing shortage of primary care physicians, NPs are part of the answer to the problem of access to acute and chronic care in both urban and rural communities. With NPs available to close this gap, it is imperative that both state and federal legislatures support initiatives that will eliminate barriers to care and promote legislation that offers full scope of practice to NPs.
We welcome your feedback on this topic. Please send your comments to NPEditor@frontline medcom.com.
REFERENCES
1. Drug Enforcement Administration. Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II (document no: 2014-19922). Federal Register. https://federalregister.gov/a/2014-19922. Accessed February 13, 2015.
2. Drug Enforcement Administration Office of Diversion. Mid-level practitioners authorization by state. www.deadiversion.usdoj.gov/drugreg/practioners. Accessed February 13, 2015.
3. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011.
4. National Council of State Boards of Nursing. The Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education (2008). www.ncsbn.org/Consen sus_Model_for_APRN_Regulation_July_2008.pdf. Accessed February 13, 2015.
5. National Council of State Boards of Nursing. Changes In Healthcare Professions’ Scope of Practice: Legislative Considerations (2009). www.ncsbn.org/ScopeofPractice_09.pdf. Accessed February 13, 2015.
From the editor: New column launches
This month we are introducing a new feature in Vascular Specialist – a column on medicolegal matters. After all there are few issues that we face as vascular surgeons that can so negatively affect our lives. For a malpractice suit can cause great financial loss even if the verdict is in our favor. Attending various depositions, trials, and meetings with attorneys is nonproductive. Not to mention the emotional toll of self-doubt, embarrassment from negative press, or resentment of a frivolous suit.
Vascular surgeons pay some of the highest insurance premiums because we deal with critical issues which may have the potential for catastrophic outcomes. Lawsuits can occur when we perform a CEA and the patient suffers a stroke or a nerve injury, or after we save a ruptured aneurysm but the patient wakes up paralyzed. We can be sued for doing too much or too little. Do a bypass for critical limb ischemic that fails or attempt a thrombectomy and ultimately perform an amputation, and we are sued for not doing a primary amputation.
Decide that a limb is beyond salvage and perform a primary amputation, and we are sued for not attempting a bypass. Further, we are often called to the operating room to save a patient who suffered an inadvertent vascular injury during a procedure by another specialist. When the lawsuit arrives, we are the ones named. In some states, lawsuits are so common and juries so biased that insurance premiums have become unaffordable. Many vascular surgeons have gone without, risking their livelihood.I believe that much can be learned from prior malpractice suits and so I have turned to Dr. O. William Brown to help develop a column dealing with lessons learned from these claims. Bill has been a President of the Society for Clinical Vascular Surgery and is an accomplished physician and educator. He is also a lawyer with a huge experience in medicolegal issues. Together we have written the first column, dealing with the issue of retroperitoneal bleeds after femoral access for endovascular procedures.
By evaluating the cases that will be presented, you will notice that there are many traps that could lead a vascular surgeon to be involved in a suit especially if the patient suffers a lethal or life-altering complication. Importantly, for newer surgeons and those in training, these cases may also be informative as to how to best manage these situations. It is possible that textbooks might not be as instructive! The cases will obviously be modified to preserve confidentiality but this information is freely available for review in the legal literature. However, since some aspects may be fictional and since there are always extenuating circumstances that these scenarios may not reflect, trial lawyers should not expect that the cases are meant to define standard of care.
A further issue with malpractice litigation is the role of the “expert witness.” Since the legal system in the United States mostly requires a trial by jury and since these so-called peers do not have our knowledge or expertise, someone must take on the responsibility of educating jurors as to the merits or demerits of the case. This is a responsibility that must not be taken lightly. The honesty and integrity of the expert needs be paramount and so we support respected authorities performing legal reviews. This requires a great deal of time and so their time should be compensated. However, all too often the expert becomes a hired gun for the attorney supporting a specious plaintiff or defense argument simply for financial gain. Such “experts” should be shunned. When their testimony becomes egregious, they should be reported to the SVS Professional Conduct committee for investigation and possible sanction. Guidelines for experts have been published by the SVS (http://www.vascularweb.org/about/policies/Pages/expert-witness-guidelines.aspx).While Dr. Brown and I hope to be able to write these columns every other month, we invite any member to contribute. You could write the column or provide us with details of a suit, or a disease process or procedure that results in complications that could land a surgeon in trouble. We would be happy to research this and, if needed, write the column for you. You may also comment on a prior column by submitting a letter to the editor. Your contribution could save a colleague from a lawsuit. More importantly it could help prevent a complication occurring in one of your patients.
Dr. Samson is the medical editor of Vascular Specialist.
This month we are introducing a new feature in Vascular Specialist – a column on medicolegal matters. After all there are few issues that we face as vascular surgeons that can so negatively affect our lives. For a malpractice suit can cause great financial loss even if the verdict is in our favor. Attending various depositions, trials, and meetings with attorneys is nonproductive. Not to mention the emotional toll of self-doubt, embarrassment from negative press, or resentment of a frivolous suit.
Vascular surgeons pay some of the highest insurance premiums because we deal with critical issues which may have the potential for catastrophic outcomes. Lawsuits can occur when we perform a CEA and the patient suffers a stroke or a nerve injury, or after we save a ruptured aneurysm but the patient wakes up paralyzed. We can be sued for doing too much or too little. Do a bypass for critical limb ischemic that fails or attempt a thrombectomy and ultimately perform an amputation, and we are sued for not doing a primary amputation.
Decide that a limb is beyond salvage and perform a primary amputation, and we are sued for not attempting a bypass. Further, we are often called to the operating room to save a patient who suffered an inadvertent vascular injury during a procedure by another specialist. When the lawsuit arrives, we are the ones named. In some states, lawsuits are so common and juries so biased that insurance premiums have become unaffordable. Many vascular surgeons have gone without, risking their livelihood.I believe that much can be learned from prior malpractice suits and so I have turned to Dr. O. William Brown to help develop a column dealing with lessons learned from these claims. Bill has been a President of the Society for Clinical Vascular Surgery and is an accomplished physician and educator. He is also a lawyer with a huge experience in medicolegal issues. Together we have written the first column, dealing with the issue of retroperitoneal bleeds after femoral access for endovascular procedures.
By evaluating the cases that will be presented, you will notice that there are many traps that could lead a vascular surgeon to be involved in a suit especially if the patient suffers a lethal or life-altering complication. Importantly, for newer surgeons and those in training, these cases may also be informative as to how to best manage these situations. It is possible that textbooks might not be as instructive! The cases will obviously be modified to preserve confidentiality but this information is freely available for review in the legal literature. However, since some aspects may be fictional and since there are always extenuating circumstances that these scenarios may not reflect, trial lawyers should not expect that the cases are meant to define standard of care.
A further issue with malpractice litigation is the role of the “expert witness.” Since the legal system in the United States mostly requires a trial by jury and since these so-called peers do not have our knowledge or expertise, someone must take on the responsibility of educating jurors as to the merits or demerits of the case. This is a responsibility that must not be taken lightly. The honesty and integrity of the expert needs be paramount and so we support respected authorities performing legal reviews. This requires a great deal of time and so their time should be compensated. However, all too often the expert becomes a hired gun for the attorney supporting a specious plaintiff or defense argument simply for financial gain. Such “experts” should be shunned. When their testimony becomes egregious, they should be reported to the SVS Professional Conduct committee for investigation and possible sanction. Guidelines for experts have been published by the SVS (http://www.vascularweb.org/about/policies/Pages/expert-witness-guidelines.aspx).While Dr. Brown and I hope to be able to write these columns every other month, we invite any member to contribute. You could write the column or provide us with details of a suit, or a disease process or procedure that results in complications that could land a surgeon in trouble. We would be happy to research this and, if needed, write the column for you. You may also comment on a prior column by submitting a letter to the editor. Your contribution could save a colleague from a lawsuit. More importantly it could help prevent a complication occurring in one of your patients.
Dr. Samson is the medical editor of Vascular Specialist.
This month we are introducing a new feature in Vascular Specialist – a column on medicolegal matters. After all there are few issues that we face as vascular surgeons that can so negatively affect our lives. For a malpractice suit can cause great financial loss even if the verdict is in our favor. Attending various depositions, trials, and meetings with attorneys is nonproductive. Not to mention the emotional toll of self-doubt, embarrassment from negative press, or resentment of a frivolous suit.
Vascular surgeons pay some of the highest insurance premiums because we deal with critical issues which may have the potential for catastrophic outcomes. Lawsuits can occur when we perform a CEA and the patient suffers a stroke or a nerve injury, or after we save a ruptured aneurysm but the patient wakes up paralyzed. We can be sued for doing too much or too little. Do a bypass for critical limb ischemic that fails or attempt a thrombectomy and ultimately perform an amputation, and we are sued for not doing a primary amputation.
Decide that a limb is beyond salvage and perform a primary amputation, and we are sued for not attempting a bypass. Further, we are often called to the operating room to save a patient who suffered an inadvertent vascular injury during a procedure by another specialist. When the lawsuit arrives, we are the ones named. In some states, lawsuits are so common and juries so biased that insurance premiums have become unaffordable. Many vascular surgeons have gone without, risking their livelihood.I believe that much can be learned from prior malpractice suits and so I have turned to Dr. O. William Brown to help develop a column dealing with lessons learned from these claims. Bill has been a President of the Society for Clinical Vascular Surgery and is an accomplished physician and educator. He is also a lawyer with a huge experience in medicolegal issues. Together we have written the first column, dealing with the issue of retroperitoneal bleeds after femoral access for endovascular procedures.
By evaluating the cases that will be presented, you will notice that there are many traps that could lead a vascular surgeon to be involved in a suit especially if the patient suffers a lethal or life-altering complication. Importantly, for newer surgeons and those in training, these cases may also be informative as to how to best manage these situations. It is possible that textbooks might not be as instructive! The cases will obviously be modified to preserve confidentiality but this information is freely available for review in the legal literature. However, since some aspects may be fictional and since there are always extenuating circumstances that these scenarios may not reflect, trial lawyers should not expect that the cases are meant to define standard of care.
A further issue with malpractice litigation is the role of the “expert witness.” Since the legal system in the United States mostly requires a trial by jury and since these so-called peers do not have our knowledge or expertise, someone must take on the responsibility of educating jurors as to the merits or demerits of the case. This is a responsibility that must not be taken lightly. The honesty and integrity of the expert needs be paramount and so we support respected authorities performing legal reviews. This requires a great deal of time and so their time should be compensated. However, all too often the expert becomes a hired gun for the attorney supporting a specious plaintiff or defense argument simply for financial gain. Such “experts” should be shunned. When their testimony becomes egregious, they should be reported to the SVS Professional Conduct committee for investigation and possible sanction. Guidelines for experts have been published by the SVS (http://www.vascularweb.org/about/policies/Pages/expert-witness-guidelines.aspx).While Dr. Brown and I hope to be able to write these columns every other month, we invite any member to contribute. You could write the column or provide us with details of a suit, or a disease process or procedure that results in complications that could land a surgeon in trouble. We would be happy to research this and, if needed, write the column for you. You may also comment on a prior column by submitting a letter to the editor. Your contribution could save a colleague from a lawsuit. More importantly it could help prevent a complication occurring in one of your patients.
Dr. Samson is the medical editor of Vascular Specialist.
Psychotic symptoms in children and adolescents
Some of the more disturbing behavioral symptoms to present are psychotic symptoms such as auditory or visual hallucination, delusions such as paranoia, or grossly disorganized thought content. Similar to the worry many families will have that a headache is the result of a brain tumor, concern that the psychotic symptoms represent the onset of schizophrenia often creates considerable alarm for families and primary care clinicians alike. In most cases, however, further evaluation suggests causes of psychotic or psychotic-like symptoms other than primary thought disorders.
Case Summary
Ella is an 8-year-old girl who has lived with her adoptive parents for 5 years. She was removed from the care of her birth parents by child protective services because of a history of abuse and neglect. Ella has struggled for many years with a variety of emotional-behavioral problems including inattention, frequent and intense angry outbursts, anxiety, and mood instability. She currently takes a long-acting methylphenidate preparation. Her parents present to her pediatrician because Ella is now reporting that she is seeing “shadows” in her room at night that frighten her. She also has lately stated that she hears a “mean voice” in her head that tells her that she is a bad person. The parents are not aware of specific psychiatric diagnoses in the birth parents, but state that they did have a history of “mental health problems” and were homeless at times. The parents are worried that these symptoms might be early signs of schizophrenia.
Discussion
Accumulating data demonstrates that while psychotic symptoms are relatively common in children and adolescents, childhood-onset schizophrenia actually is quite rare. Estimates of psychotic symptoms in otherwise healthy children have been as high as 5%, with a recent study of adolescents reporting that 15% of the sample reported hearing a voice that commented on what the person was thinking or feeling (Schizophr. Bull. 2014;40:868-77). At the same time, the incidence of childhood-onset schizophrenia is thought to be less than 0.04% based on data from a group at the National Institute of Mental Health (Child Adolesc. Psychiatr. Clin. N. Am. 2013;22:539-55). This group has been actively evaluating and recruiting children with early onset psychosis and finds that more than 90% of their referrals end up with a diagnosis other than schizophrenia.
The differential diagnosis for psychosis is extensive. In terms of nonpsychiatric diagnoses (what in the past were referred to as “organic” causes), possible etiologies include CNS tumors, encephalitis, metabolic disorders, and various genetic conditions, among others. Some medications, such as corticosteroids, stimulants, and anticholinergic medications, also can result in psychotic symptoms, especially at higher doses. While the acute presence of psychotic symptoms in an otherwise healthy child should certainly prompt suspicion of a possible delirium or other nonpsychiatric condition, it is important to note that some of the above etiologies can be associated with other types of behavioral disturbances; thus, the presence of earlier behavioral problems does not rule out the possibility that one of these nonpsychiatric causes is present.
Clinical tip: From our experience at a busy outpatient child psychiatry clinic, it is often not clear whose job it is to rule out nonpsychiatric causes of behavior problems. There is a risk that the psychiatrist assumes that the pediatrician has done this work-up while the pediatrician assumes that this component is part of a psychiatric evaluation. Communication about this role is important. If a third specialist is needed, such as a pediatric neurologist or geneticist, then it is important to clarify who will initiate that consultation as well.
The differential for psychotic symptoms also includes a number of psychiatric conditions other than schizophrenia, such as bipolar or unipolar depression, obsessive-compulsive disorder, posttraumatic stress disorder, autism, or an eating disorder. Substance use, particularly cannabis, also needs to be strongly considered. A child psychiatrist or other mental health professional can be very helpful here to help decipher what are sometimes subtle differences in the nature and content of the psychotic symptoms between various diagnoses. Receptive and expressive language disorders also can be present in many youth who experience psychotic symptoms.
The decision of if and when to begin treatment with an antipsychotic medication can be a difficult one and should be made very thoughtfully and with the help of consultation. The concern that a longer duration of untreated psychosis may be related to a more protracted course needs to be weighed against other data suggesting that using as little medication as possible may predict higher levels of future functioning (JAMA Psychiatry 2013;70:913-20). It is important to note that there are many nonpharmacological interventions that also can be helpful, including individual and family psychotherapy, family education, school modifications, and other social supports.
Case follow-up
Ella was referred to a child psychologist who performed an evaluation and thought that the patient’s symptoms were most representative of posttraumatic stress disorder. She began treatment with trauma-focused cognitive-behavioral therapy (TF-CBT) which led to a reduction in both her anxiety and psychotic-sounding symptoms.
Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at pdnews@frontlinemedcom.com.
Some of the more disturbing behavioral symptoms to present are psychotic symptoms such as auditory or visual hallucination, delusions such as paranoia, or grossly disorganized thought content. Similar to the worry many families will have that a headache is the result of a brain tumor, concern that the psychotic symptoms represent the onset of schizophrenia often creates considerable alarm for families and primary care clinicians alike. In most cases, however, further evaluation suggests causes of psychotic or psychotic-like symptoms other than primary thought disorders.
Case Summary
Ella is an 8-year-old girl who has lived with her adoptive parents for 5 years. She was removed from the care of her birth parents by child protective services because of a history of abuse and neglect. Ella has struggled for many years with a variety of emotional-behavioral problems including inattention, frequent and intense angry outbursts, anxiety, and mood instability. She currently takes a long-acting methylphenidate preparation. Her parents present to her pediatrician because Ella is now reporting that she is seeing “shadows” in her room at night that frighten her. She also has lately stated that she hears a “mean voice” in her head that tells her that she is a bad person. The parents are not aware of specific psychiatric diagnoses in the birth parents, but state that they did have a history of “mental health problems” and were homeless at times. The parents are worried that these symptoms might be early signs of schizophrenia.
Discussion
Accumulating data demonstrates that while psychotic symptoms are relatively common in children and adolescents, childhood-onset schizophrenia actually is quite rare. Estimates of psychotic symptoms in otherwise healthy children have been as high as 5%, with a recent study of adolescents reporting that 15% of the sample reported hearing a voice that commented on what the person was thinking or feeling (Schizophr. Bull. 2014;40:868-77). At the same time, the incidence of childhood-onset schizophrenia is thought to be less than 0.04% based on data from a group at the National Institute of Mental Health (Child Adolesc. Psychiatr. Clin. N. Am. 2013;22:539-55). This group has been actively evaluating and recruiting children with early onset psychosis and finds that more than 90% of their referrals end up with a diagnosis other than schizophrenia.
The differential diagnosis for psychosis is extensive. In terms of nonpsychiatric diagnoses (what in the past were referred to as “organic” causes), possible etiologies include CNS tumors, encephalitis, metabolic disorders, and various genetic conditions, among others. Some medications, such as corticosteroids, stimulants, and anticholinergic medications, also can result in psychotic symptoms, especially at higher doses. While the acute presence of psychotic symptoms in an otherwise healthy child should certainly prompt suspicion of a possible delirium or other nonpsychiatric condition, it is important to note that some of the above etiologies can be associated with other types of behavioral disturbances; thus, the presence of earlier behavioral problems does not rule out the possibility that one of these nonpsychiatric causes is present.
Clinical tip: From our experience at a busy outpatient child psychiatry clinic, it is often not clear whose job it is to rule out nonpsychiatric causes of behavior problems. There is a risk that the psychiatrist assumes that the pediatrician has done this work-up while the pediatrician assumes that this component is part of a psychiatric evaluation. Communication about this role is important. If a third specialist is needed, such as a pediatric neurologist or geneticist, then it is important to clarify who will initiate that consultation as well.
The differential for psychotic symptoms also includes a number of psychiatric conditions other than schizophrenia, such as bipolar or unipolar depression, obsessive-compulsive disorder, posttraumatic stress disorder, autism, or an eating disorder. Substance use, particularly cannabis, also needs to be strongly considered. A child psychiatrist or other mental health professional can be very helpful here to help decipher what are sometimes subtle differences in the nature and content of the psychotic symptoms between various diagnoses. Receptive and expressive language disorders also can be present in many youth who experience psychotic symptoms.
The decision of if and when to begin treatment with an antipsychotic medication can be a difficult one and should be made very thoughtfully and with the help of consultation. The concern that a longer duration of untreated psychosis may be related to a more protracted course needs to be weighed against other data suggesting that using as little medication as possible may predict higher levels of future functioning (JAMA Psychiatry 2013;70:913-20). It is important to note that there are many nonpharmacological interventions that also can be helpful, including individual and family psychotherapy, family education, school modifications, and other social supports.
Case follow-up
Ella was referred to a child psychologist who performed an evaluation and thought that the patient’s symptoms were most representative of posttraumatic stress disorder. She began treatment with trauma-focused cognitive-behavioral therapy (TF-CBT) which led to a reduction in both her anxiety and psychotic-sounding symptoms.
Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at pdnews@frontlinemedcom.com.
Some of the more disturbing behavioral symptoms to present are psychotic symptoms such as auditory or visual hallucination, delusions such as paranoia, or grossly disorganized thought content. Similar to the worry many families will have that a headache is the result of a brain tumor, concern that the psychotic symptoms represent the onset of schizophrenia often creates considerable alarm for families and primary care clinicians alike. In most cases, however, further evaluation suggests causes of psychotic or psychotic-like symptoms other than primary thought disorders.
Case Summary
Ella is an 8-year-old girl who has lived with her adoptive parents for 5 years. She was removed from the care of her birth parents by child protective services because of a history of abuse and neglect. Ella has struggled for many years with a variety of emotional-behavioral problems including inattention, frequent and intense angry outbursts, anxiety, and mood instability. She currently takes a long-acting methylphenidate preparation. Her parents present to her pediatrician because Ella is now reporting that she is seeing “shadows” in her room at night that frighten her. She also has lately stated that she hears a “mean voice” in her head that tells her that she is a bad person. The parents are not aware of specific psychiatric diagnoses in the birth parents, but state that they did have a history of “mental health problems” and were homeless at times. The parents are worried that these symptoms might be early signs of schizophrenia.
Discussion
Accumulating data demonstrates that while psychotic symptoms are relatively common in children and adolescents, childhood-onset schizophrenia actually is quite rare. Estimates of psychotic symptoms in otherwise healthy children have been as high as 5%, with a recent study of adolescents reporting that 15% of the sample reported hearing a voice that commented on what the person was thinking or feeling (Schizophr. Bull. 2014;40:868-77). At the same time, the incidence of childhood-onset schizophrenia is thought to be less than 0.04% based on data from a group at the National Institute of Mental Health (Child Adolesc. Psychiatr. Clin. N. Am. 2013;22:539-55). This group has been actively evaluating and recruiting children with early onset psychosis and finds that more than 90% of their referrals end up with a diagnosis other than schizophrenia.
The differential diagnosis for psychosis is extensive. In terms of nonpsychiatric diagnoses (what in the past were referred to as “organic” causes), possible etiologies include CNS tumors, encephalitis, metabolic disorders, and various genetic conditions, among others. Some medications, such as corticosteroids, stimulants, and anticholinergic medications, also can result in psychotic symptoms, especially at higher doses. While the acute presence of psychotic symptoms in an otherwise healthy child should certainly prompt suspicion of a possible delirium or other nonpsychiatric condition, it is important to note that some of the above etiologies can be associated with other types of behavioral disturbances; thus, the presence of earlier behavioral problems does not rule out the possibility that one of these nonpsychiatric causes is present.
Clinical tip: From our experience at a busy outpatient child psychiatry clinic, it is often not clear whose job it is to rule out nonpsychiatric causes of behavior problems. There is a risk that the psychiatrist assumes that the pediatrician has done this work-up while the pediatrician assumes that this component is part of a psychiatric evaluation. Communication about this role is important. If a third specialist is needed, such as a pediatric neurologist or geneticist, then it is important to clarify who will initiate that consultation as well.
The differential for psychotic symptoms also includes a number of psychiatric conditions other than schizophrenia, such as bipolar or unipolar depression, obsessive-compulsive disorder, posttraumatic stress disorder, autism, or an eating disorder. Substance use, particularly cannabis, also needs to be strongly considered. A child psychiatrist or other mental health professional can be very helpful here to help decipher what are sometimes subtle differences in the nature and content of the psychotic symptoms between various diagnoses. Receptive and expressive language disorders also can be present in many youth who experience psychotic symptoms.
The decision of if and when to begin treatment with an antipsychotic medication can be a difficult one and should be made very thoughtfully and with the help of consultation. The concern that a longer duration of untreated psychosis may be related to a more protracted course needs to be weighed against other data suggesting that using as little medication as possible may predict higher levels of future functioning (JAMA Psychiatry 2013;70:913-20). It is important to note that there are many nonpharmacological interventions that also can be helpful, including individual and family psychotherapy, family education, school modifications, and other social supports.
Case follow-up
Ella was referred to a child psychologist who performed an evaluation and thought that the patient’s symptoms were most representative of posttraumatic stress disorder. She began treatment with trauma-focused cognitive-behavioral therapy (TF-CBT) which led to a reduction in both her anxiety and psychotic-sounding symptoms.
Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Rettew said he has no relevant financial disclosures. Follow him on Twitter @pedipsych. E-mail him at pdnews@frontlinemedcom.com.
In co-management, do what’s best for the patient in a timely fashion
Deferring management of a postop complication to the surgery team resulted in treatment delay with a serious adverse outcome.
History:
RR is a 54 year-old man with a medical history of hypertension, hyperlipidemia, obesity, and chronic left knee pain from osteoarthritis. He was admitted to the hospital and underwent an elective left total knee replacement with monitored anesthesia care, combined with a left femoral nerve block. There were no intraoperative complications. When RR awoke in the recovery unit, he was in excruciating pain. He received another femoral nerve block and was sent to the regular nursing floor around 4 p.m. By early evening, the pain in his left leg remained poorly controlled and was consistently rated as 10/10. In addition, RR’s heart rates were elevated (130-140 bpm). The orthopedic surgeon was notified of the uncontrolled pain and elevated heart rates and he requested a hospitalist consult.
Dr. Hospitalist saw RR sometime before 9 p.m. that evening. RR was somewhat sedated by opiate analgesics, and his wife was at the bedside. During the interview, she related that her husband had been taking nightly benzodiazepines for sleep for several months leading up to the surgery. Dr. Hospitalist did not examine RR’s left foot and leg, and he documented in his consult that he was deferring left leg issues such as bleeding and swelling to the orthopedic surgery team. Dr. Hospitalist’s impression was that RR had sinus tachycardia, possibly because of the benzodiazepine withdrawal. Fluids were ordered along with low-dose benzodiazepines.
Throughout the night, RR awakened and complained of severe pain. The evening nurse charted that RR was having difficulty moving the toes on his left foot and that the pulses in his foot were barely palpable. By the early morning, RR’s pulses were no longer palpable but could still be detected by Doppler. Examination by the surgical team the following morning documented that RR had decreased sensation in his left lower extremity as well. An ultrasound of the left leg was ordered and revealed a large left popliteal pseudoaneurysm with complete occlusion of the left popliteal, tibial, and peroneal arteries below the knee. The patient went to the operating room three times over the next 4 days in an attempt to revascularize the leg. Unfortunately, RR ultimately had an above-the-knee amputation (AKA) performed 9 days after his elective total knee replacement.
Complaint:
RR sought a “quality of life”–enhancing procedure for his chronic left knee pain. What he ended up with was an AKA and a significant decrease in his overall quality of life. RR was angry that his postoperative pain, which was out of proportion to what should have been expected for this type of surgery, was essentially ignored until it was too late. He blamed the surgeon and the hospitalist for failing to diagnose his condition while his leg was still salvageable.
Scientific principles:
Complications during and after total knee replacement are generally uncommon and can often be prevented with meticulous surgical technique and with attentive postoperative management. Vascular injuries in total knee arthroplasty are exceedingly rare, but careful examination of the limbs is necessary to detect signs of acute limb ischemia. The six P’s of acute ischemia include paresthesia, pain, pallor, pulselessness, poikilothermia, and paralysis. A diagnosis of acute lower extremity ischemia can generally be made based upon the history and physical examination. Once the diagnosis of acute arterial occlusion has been made, anticoagulation should be initiated. Subsequent treatment varies depending upon the classification of acute ischemia. The initial options include catheter-directed thrombolytic therapy with or without percutaneous intervention or surgery.
Complaint rebuttal and discussion:
Dr. Hospitalist defended himself by limiting his scope of responsibility. He essentially said this was a surgical complication, and it was therefore the surgical team’s responsibility to make the diagnosis. Defense experts were quick to affirm that Dr. Hospitalist was consulted for a specific issue – postoperative tachycardia – and that he performed a focused history and physical examination to address that issue. Plaintiff experts cited the Society of Hospital Medicine Hospitalist Orthopedic Co-Management Implementation Guide, which outlines that co-management is the “shared responsibility, authority, and accountability for the care of a hospitalized patient.” The Guide further states: “Inevitably, there will be circumstances where either of the co-managing services could manage a specific problem, or where it is unclear which service would be best equipped to manage a specific problem. These situations can be best managed by following two basic principles: 1) Do what is best for the patient in a timely fashion and do not assume that a problem is being handled by the other service; and 2) communicate frequently and directly with the other service.” Plaintiff experts argued that Dr. Hospitalist failed to follow both of these principles.
Conclusion:
Hospitalists are frequently co-managers of surgical patients, and thus they are in part responsible for evaluating diagnosing, and treating both medical and surgical complications. Once again, it is vital that hospitalists delineate responsibilities explicitly through direct communication and then memorialize such discussions in the medical record. In this case, the chart consultation deferred examination of the operative leg to a surgical team that claimed they were “unaware” of any issues. This case was settled on behalf of the patient for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at eHospitalist news.com/Lessons.
Deferring management of a postop complication to the surgery team resulted in treatment delay with a serious adverse outcome.
History:
RR is a 54 year-old man with a medical history of hypertension, hyperlipidemia, obesity, and chronic left knee pain from osteoarthritis. He was admitted to the hospital and underwent an elective left total knee replacement with monitored anesthesia care, combined with a left femoral nerve block. There were no intraoperative complications. When RR awoke in the recovery unit, he was in excruciating pain. He received another femoral nerve block and was sent to the regular nursing floor around 4 p.m. By early evening, the pain in his left leg remained poorly controlled and was consistently rated as 10/10. In addition, RR’s heart rates were elevated (130-140 bpm). The orthopedic surgeon was notified of the uncontrolled pain and elevated heart rates and he requested a hospitalist consult.
Dr. Hospitalist saw RR sometime before 9 p.m. that evening. RR was somewhat sedated by opiate analgesics, and his wife was at the bedside. During the interview, she related that her husband had been taking nightly benzodiazepines for sleep for several months leading up to the surgery. Dr. Hospitalist did not examine RR’s left foot and leg, and he documented in his consult that he was deferring left leg issues such as bleeding and swelling to the orthopedic surgery team. Dr. Hospitalist’s impression was that RR had sinus tachycardia, possibly because of the benzodiazepine withdrawal. Fluids were ordered along with low-dose benzodiazepines.
Throughout the night, RR awakened and complained of severe pain. The evening nurse charted that RR was having difficulty moving the toes on his left foot and that the pulses in his foot were barely palpable. By the early morning, RR’s pulses were no longer palpable but could still be detected by Doppler. Examination by the surgical team the following morning documented that RR had decreased sensation in his left lower extremity as well. An ultrasound of the left leg was ordered and revealed a large left popliteal pseudoaneurysm with complete occlusion of the left popliteal, tibial, and peroneal arteries below the knee. The patient went to the operating room three times over the next 4 days in an attempt to revascularize the leg. Unfortunately, RR ultimately had an above-the-knee amputation (AKA) performed 9 days after his elective total knee replacement.
Complaint:
RR sought a “quality of life”–enhancing procedure for his chronic left knee pain. What he ended up with was an AKA and a significant decrease in his overall quality of life. RR was angry that his postoperative pain, which was out of proportion to what should have been expected for this type of surgery, was essentially ignored until it was too late. He blamed the surgeon and the hospitalist for failing to diagnose his condition while his leg was still salvageable.
Scientific principles:
Complications during and after total knee replacement are generally uncommon and can often be prevented with meticulous surgical technique and with attentive postoperative management. Vascular injuries in total knee arthroplasty are exceedingly rare, but careful examination of the limbs is necessary to detect signs of acute limb ischemia. The six P’s of acute ischemia include paresthesia, pain, pallor, pulselessness, poikilothermia, and paralysis. A diagnosis of acute lower extremity ischemia can generally be made based upon the history and physical examination. Once the diagnosis of acute arterial occlusion has been made, anticoagulation should be initiated. Subsequent treatment varies depending upon the classification of acute ischemia. The initial options include catheter-directed thrombolytic therapy with or without percutaneous intervention or surgery.
Complaint rebuttal and discussion:
Dr. Hospitalist defended himself by limiting his scope of responsibility. He essentially said this was a surgical complication, and it was therefore the surgical team’s responsibility to make the diagnosis. Defense experts were quick to affirm that Dr. Hospitalist was consulted for a specific issue – postoperative tachycardia – and that he performed a focused history and physical examination to address that issue. Plaintiff experts cited the Society of Hospital Medicine Hospitalist Orthopedic Co-Management Implementation Guide, which outlines that co-management is the “shared responsibility, authority, and accountability for the care of a hospitalized patient.” The Guide further states: “Inevitably, there will be circumstances where either of the co-managing services could manage a specific problem, or where it is unclear which service would be best equipped to manage a specific problem. These situations can be best managed by following two basic principles: 1) Do what is best for the patient in a timely fashion and do not assume that a problem is being handled by the other service; and 2) communicate frequently and directly with the other service.” Plaintiff experts argued that Dr. Hospitalist failed to follow both of these principles.
Conclusion:
Hospitalists are frequently co-managers of surgical patients, and thus they are in part responsible for evaluating diagnosing, and treating both medical and surgical complications. Once again, it is vital that hospitalists delineate responsibilities explicitly through direct communication and then memorialize such discussions in the medical record. In this case, the chart consultation deferred examination of the operative leg to a surgical team that claimed they were “unaware” of any issues. This case was settled on behalf of the patient for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at eHospitalist news.com/Lessons.
Deferring management of a postop complication to the surgery team resulted in treatment delay with a serious adverse outcome.
History:
RR is a 54 year-old man with a medical history of hypertension, hyperlipidemia, obesity, and chronic left knee pain from osteoarthritis. He was admitted to the hospital and underwent an elective left total knee replacement with monitored anesthesia care, combined with a left femoral nerve block. There were no intraoperative complications. When RR awoke in the recovery unit, he was in excruciating pain. He received another femoral nerve block and was sent to the regular nursing floor around 4 p.m. By early evening, the pain in his left leg remained poorly controlled and was consistently rated as 10/10. In addition, RR’s heart rates were elevated (130-140 bpm). The orthopedic surgeon was notified of the uncontrolled pain and elevated heart rates and he requested a hospitalist consult.
Dr. Hospitalist saw RR sometime before 9 p.m. that evening. RR was somewhat sedated by opiate analgesics, and his wife was at the bedside. During the interview, she related that her husband had been taking nightly benzodiazepines for sleep for several months leading up to the surgery. Dr. Hospitalist did not examine RR’s left foot and leg, and he documented in his consult that he was deferring left leg issues such as bleeding and swelling to the orthopedic surgery team. Dr. Hospitalist’s impression was that RR had sinus tachycardia, possibly because of the benzodiazepine withdrawal. Fluids were ordered along with low-dose benzodiazepines.
Throughout the night, RR awakened and complained of severe pain. The evening nurse charted that RR was having difficulty moving the toes on his left foot and that the pulses in his foot were barely palpable. By the early morning, RR’s pulses were no longer palpable but could still be detected by Doppler. Examination by the surgical team the following morning documented that RR had decreased sensation in his left lower extremity as well. An ultrasound of the left leg was ordered and revealed a large left popliteal pseudoaneurysm with complete occlusion of the left popliteal, tibial, and peroneal arteries below the knee. The patient went to the operating room three times over the next 4 days in an attempt to revascularize the leg. Unfortunately, RR ultimately had an above-the-knee amputation (AKA) performed 9 days after his elective total knee replacement.
Complaint:
RR sought a “quality of life”–enhancing procedure for his chronic left knee pain. What he ended up with was an AKA and a significant decrease in his overall quality of life. RR was angry that his postoperative pain, which was out of proportion to what should have been expected for this type of surgery, was essentially ignored until it was too late. He blamed the surgeon and the hospitalist for failing to diagnose his condition while his leg was still salvageable.
Scientific principles:
Complications during and after total knee replacement are generally uncommon and can often be prevented with meticulous surgical technique and with attentive postoperative management. Vascular injuries in total knee arthroplasty are exceedingly rare, but careful examination of the limbs is necessary to detect signs of acute limb ischemia. The six P’s of acute ischemia include paresthesia, pain, pallor, pulselessness, poikilothermia, and paralysis. A diagnosis of acute lower extremity ischemia can generally be made based upon the history and physical examination. Once the diagnosis of acute arterial occlusion has been made, anticoagulation should be initiated. Subsequent treatment varies depending upon the classification of acute ischemia. The initial options include catheter-directed thrombolytic therapy with or without percutaneous intervention or surgery.
Complaint rebuttal and discussion:
Dr. Hospitalist defended himself by limiting his scope of responsibility. He essentially said this was a surgical complication, and it was therefore the surgical team’s responsibility to make the diagnosis. Defense experts were quick to affirm that Dr. Hospitalist was consulted for a specific issue – postoperative tachycardia – and that he performed a focused history and physical examination to address that issue. Plaintiff experts cited the Society of Hospital Medicine Hospitalist Orthopedic Co-Management Implementation Guide, which outlines that co-management is the “shared responsibility, authority, and accountability for the care of a hospitalized patient.” The Guide further states: “Inevitably, there will be circumstances where either of the co-managing services could manage a specific problem, or where it is unclear which service would be best equipped to manage a specific problem. These situations can be best managed by following two basic principles: 1) Do what is best for the patient in a timely fashion and do not assume that a problem is being handled by the other service; and 2) communicate frequently and directly with the other service.” Plaintiff experts argued that Dr. Hospitalist failed to follow both of these principles.
Conclusion:
Hospitalists are frequently co-managers of surgical patients, and thus they are in part responsible for evaluating diagnosing, and treating both medical and surgical complications. Once again, it is vital that hospitalists delineate responsibilities explicitly through direct communication and then memorialize such discussions in the medical record. In this case, the chart consultation deferred examination of the operative leg to a surgical team that claimed they were “unaware” of any issues. This case was settled on behalf of the patient for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at eHospitalist news.com/Lessons.
Never inject epinephrine in the fingers or toes?
A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?
A. 1% lidocaine.
B. 1% lidocaine with epinephrine.
C. Bupivacaine.
Myth: You should not use lidocaine with epinephrine on a digit.
Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).
Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.
Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.
A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.
There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.
In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).
Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.
There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).
In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.
The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.
Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at dpaauw@uw.edu.
A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?
A. 1% lidocaine.
B. 1% lidocaine with epinephrine.
C. Bupivacaine.
Myth: You should not use lidocaine with epinephrine on a digit.
Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).
Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.
Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.
A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.
There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.
In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).
Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.
There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).
In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.
The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.
Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at dpaauw@uw.edu.
A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?
A. 1% lidocaine.
B. 1% lidocaine with epinephrine.
C. Bupivacaine.
Myth: You should not use lidocaine with epinephrine on a digit.
Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).
Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.
Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.
A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.
There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.
In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).
Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.
There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).
In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.
The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.
Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at dpaauw@uw.edu.
Walking in their shoes
When doctors become patients, the experience forces us to better our ability to practice the art of medicine because we gain more empathy and are able to relate to our patients’ feelings on a different level.
It’s one thing to read about the conditions we treat, and quite another when we are the ones lying flat on our backs looking up at the faces of complete strangers whom we are expected to trust for compassionate, competent, and sometimes life-altering care.
One of my first brushes with walking in my patients’ shoes was undergoing an MRI. Patients’ concerns that I had considered irrational and unfounded became understandable as I lay in the machine, unable to see anything but the inside of a tube or to move more than a few inches in any direction. All I could hear was the incessant, loud clicking of the machine as it took image after image. Alone with my thoughts, and the uncertainty of the test results, I could truly empathize with my patients’ anxieties about the procedure.
If you have never personally experienced a significant illness, I strongly recommend watching a movie called “The Doctor.” Early in my career, I remember watching this movie and it had a profound impact, the next best thing to getting sick myself, so to speak. The main character, played by William Hurt, is a brilliant, albeit insensitive doctor who is diagnosed with cancer and forced to deal in his most vulnerable state with the frustration of an inefficient medical system. Perhaps most intriguing, he is confronted head on with his own mortality and must seemingly place his trust in the hands of another brilliant and cold clinician. The result is a moving storyline; if you have never been seriously ill, this movie might just forever change your practice style.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.
When doctors become patients, the experience forces us to better our ability to practice the art of medicine because we gain more empathy and are able to relate to our patients’ feelings on a different level.
It’s one thing to read about the conditions we treat, and quite another when we are the ones lying flat on our backs looking up at the faces of complete strangers whom we are expected to trust for compassionate, competent, and sometimes life-altering care.
One of my first brushes with walking in my patients’ shoes was undergoing an MRI. Patients’ concerns that I had considered irrational and unfounded became understandable as I lay in the machine, unable to see anything but the inside of a tube or to move more than a few inches in any direction. All I could hear was the incessant, loud clicking of the machine as it took image after image. Alone with my thoughts, and the uncertainty of the test results, I could truly empathize with my patients’ anxieties about the procedure.
If you have never personally experienced a significant illness, I strongly recommend watching a movie called “The Doctor.” Early in my career, I remember watching this movie and it had a profound impact, the next best thing to getting sick myself, so to speak. The main character, played by William Hurt, is a brilliant, albeit insensitive doctor who is diagnosed with cancer and forced to deal in his most vulnerable state with the frustration of an inefficient medical system. Perhaps most intriguing, he is confronted head on with his own mortality and must seemingly place his trust in the hands of another brilliant and cold clinician. The result is a moving storyline; if you have never been seriously ill, this movie might just forever change your practice style.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.
When doctors become patients, the experience forces us to better our ability to practice the art of medicine because we gain more empathy and are able to relate to our patients’ feelings on a different level.
It’s one thing to read about the conditions we treat, and quite another when we are the ones lying flat on our backs looking up at the faces of complete strangers whom we are expected to trust for compassionate, competent, and sometimes life-altering care.
One of my first brushes with walking in my patients’ shoes was undergoing an MRI. Patients’ concerns that I had considered irrational and unfounded became understandable as I lay in the machine, unable to see anything but the inside of a tube or to move more than a few inches in any direction. All I could hear was the incessant, loud clicking of the machine as it took image after image. Alone with my thoughts, and the uncertainty of the test results, I could truly empathize with my patients’ anxieties about the procedure.
If you have never personally experienced a significant illness, I strongly recommend watching a movie called “The Doctor.” Early in my career, I remember watching this movie and it had a profound impact, the next best thing to getting sick myself, so to speak. The main character, played by William Hurt, is a brilliant, albeit insensitive doctor who is diagnosed with cancer and forced to deal in his most vulnerable state with the frustration of an inefficient medical system. Perhaps most intriguing, he is confronted head on with his own mortality and must seemingly place his trust in the hands of another brilliant and cold clinician. The result is a moving storyline; if you have never been seriously ill, this movie might just forever change your practice style.
Dr. Hester is a hospitalist at Baltimore-Washington Medical Center in Glen Burnie, Md. She is the creator of the Patient Whiz, a patient-engagement app for iOS. Reach her at healthsavvy@aol.com.
Time to change our advice on alcohol
Alcohol is a drug, the abuse of which is the third leading cause of preventable death and disability in the United States. Most clinicians intuitively appreciate that 80% of drinkers consume only 20% of all the alcohol consumed in the United States. In other words, most problem drinkers consume most of the alcohol and most drinkers are not problem drinkers. Perhaps as a result, clinicians may recommend the consumption of alcohol in moderation for its putative health promoting effects (e.g., reduction in cardiovascular events and increases in HDL), hoping that patients can benefit without being put at risk.
I am personally guilty of such allowances among patients who already consume modestly. With all the potential negative consequences of alcohol use, it might not have taken much for me to change my clinical advice-giving.
Knott and colleagues conducted a population based study from the Health Survey for England encompassing the years 1998-2008 linked to national mortality data. The investigators observed that compared with never drinkers, protective effects of alcohol were limited to younger men (aged 50-64 years) and older women (≥ 65 years).
What this study adds to the literature is a cleaner comparison between alcohol consumers and never drinkers and adjustments for additional confounders. Many of the previous studies showing alcohol’s beneficial effects have included former drinkers in the nondrinker comparison group; however, former drinkers have a higher mortality risk than do never drinkers because they tend to be unhealthier than never drinkers. Compared to a healthier population of never drinkers, alcohol’s effects attenuate. The use of additional adjustment variables not used in previous studies also attenuated the effect of alcohol.
As patients age, their ability to metabolize and eliminate alcohol changes. Such alterations can lead to increased adverse health consequences and accidents. If the benefit of alcohol is not as great as we previously thought, maybe the time has come to change our advice on alcohol.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
Alcohol is a drug, the abuse of which is the third leading cause of preventable death and disability in the United States. Most clinicians intuitively appreciate that 80% of drinkers consume only 20% of all the alcohol consumed in the United States. In other words, most problem drinkers consume most of the alcohol and most drinkers are not problem drinkers. Perhaps as a result, clinicians may recommend the consumption of alcohol in moderation for its putative health promoting effects (e.g., reduction in cardiovascular events and increases in HDL), hoping that patients can benefit without being put at risk.
I am personally guilty of such allowances among patients who already consume modestly. With all the potential negative consequences of alcohol use, it might not have taken much for me to change my clinical advice-giving.
Knott and colleagues conducted a population based study from the Health Survey for England encompassing the years 1998-2008 linked to national mortality data. The investigators observed that compared with never drinkers, protective effects of alcohol were limited to younger men (aged 50-64 years) and older women (≥ 65 years).
What this study adds to the literature is a cleaner comparison between alcohol consumers and never drinkers and adjustments for additional confounders. Many of the previous studies showing alcohol’s beneficial effects have included former drinkers in the nondrinker comparison group; however, former drinkers have a higher mortality risk than do never drinkers because they tend to be unhealthier than never drinkers. Compared to a healthier population of never drinkers, alcohol’s effects attenuate. The use of additional adjustment variables not used in previous studies also attenuated the effect of alcohol.
As patients age, their ability to metabolize and eliminate alcohol changes. Such alterations can lead to increased adverse health consequences and accidents. If the benefit of alcohol is not as great as we previously thought, maybe the time has come to change our advice on alcohol.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
Alcohol is a drug, the abuse of which is the third leading cause of preventable death and disability in the United States. Most clinicians intuitively appreciate that 80% of drinkers consume only 20% of all the alcohol consumed in the United States. In other words, most problem drinkers consume most of the alcohol and most drinkers are not problem drinkers. Perhaps as a result, clinicians may recommend the consumption of alcohol in moderation for its putative health promoting effects (e.g., reduction in cardiovascular events and increases in HDL), hoping that patients can benefit without being put at risk.
I am personally guilty of such allowances among patients who already consume modestly. With all the potential negative consequences of alcohol use, it might not have taken much for me to change my clinical advice-giving.
Knott and colleagues conducted a population based study from the Health Survey for England encompassing the years 1998-2008 linked to national mortality data. The investigators observed that compared with never drinkers, protective effects of alcohol were limited to younger men (aged 50-64 years) and older women (≥ 65 years).
What this study adds to the literature is a cleaner comparison between alcohol consumers and never drinkers and adjustments for additional confounders. Many of the previous studies showing alcohol’s beneficial effects have included former drinkers in the nondrinker comparison group; however, former drinkers have a higher mortality risk than do never drinkers because they tend to be unhealthier than never drinkers. Compared to a healthier population of never drinkers, alcohol’s effects attenuate. The use of additional adjustment variables not used in previous studies also attenuated the effect of alcohol.
As patients age, their ability to metabolize and eliminate alcohol changes. Such alterations can lead to increased adverse health consequences and accidents. If the benefit of alcohol is not as great as we previously thought, maybe the time has come to change our advice on alcohol.
Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
It’s time to take a stand against vaccine refusers
The challenges in primary care are many, and one of increasing importance is what to say to vaccine refusers. After much debate and thoughtful discussion, my medical partner, Dr. Janet Casey at Legacy Pediatrics, decided that the practice would refuse to care for the refusers.
Over the years, I have accepted such patients into my practice and worked with them to gain their confidence and debunk the many myths about the safety of vaccination that are so visible on the Internet. The approach worked well, and by the time the children were 1 year of age, I cannot remember but a handful of parents who did not come around to realize that it was best to vaccinate. However, with the recent measles outbreak at Disneyland in California, pertussis at epidemic proportions in pockets of the United States and elsewhere in the world, and the antivaccine voices gaining more and more attention, I agree, it is time to take a stand.
When a family brings their unvaccinated or undervaccinated child into the waiting room of a physician’s practice, that family is potentially exposing others in that waiting room to serious infectious diseases – that is not fair. In the waiting room may well be a patient who is on chemotherapy or immunotherapy or otherwise immunocompromised, and he relies on the “herd immunity” achieved by vaccinations of those who can safely be vaccinated for individual protection and public health. Those patients who have weakened immune systems did not choose to have their medical condition, whereas the vaccine refusers are choosing not to vaccinate their child (or typically themselves as well). And the reasons they are choosing not to vaccinate are based on misrepresentation of medical facts, fabrications of safety concerns, long ago disproven speculations by well-meaning and not so well-meaning physicians and scientists, pseudoscience published in pseudoscientific journals, and/or general distrust of the federal government that mandates vaccinations for the good of the public health.
My personal experience with vaccine scares dates back to a time when whole-cell pertussis vaccine was the only pertussis vaccine available. I was a medical student, resident, and then an infectious diseases fellow during the escalating debate about the significant side effects of vaccines. I joined in the chorus of voices questioning the need for clear data on the problem, and then the pursuit of a safer acellular pertussis vaccine. The physician community and the public were ready for change, and the National Institutes of Health took the lead in organizing multiple studies and clinical trials leading to eventual replacement of the whole cell pertussis vaccine with the current acellular vaccines.
Much more recently, at the request of National Institutes of Health, I led studies of the safety of thimerosal preservative in multidose vaccine vials that appeared in the Lancet (2002;360:1737-41); Pediatrics (2008;121:e208-14) and the Journal of Pediatrics (2009;155:495-9). Using the data from those three studies, the World Health Organization (WHO), the United Nations, the Institute of Medicine, and other organizations were able to see that the metabolism and elimination from the body of ethylmercury in thimerosal was dramatically faster, compared with methylmercury in fish. Therefore, the presumption of possible accumulation of mercury in the body of infants receiving vaccines from multidose vials when such vaccines were closely spaced was disproven by scientific data.
In plain language, there was never a known risk from thimerosal, but a premature, hurried decision was made to mandate removal of thimerosal from vaccines given to children in the United States and western Europe; thereby the myth lives on that thimerosal is not safe. Yet thimerosal is safe, and the WHO continues to advocate use of thimerosal in multidose vaccine vials. Nevertheless, I have been criticized personally on the Internet for this work. The accusation is that I, the rest of the scientists who participated in the study, and the NIH oversight were biased because our academic institutions had previously received funding from vaccine companies to perform clinical and translational research. I received many hate e-mails and even a death threat.
To close this column with a sense of humor, I suggest you Google the responses by U.S. presidential hopefuls on their stand with regard to vaccine refusers. The comments, then the reversal and “corrections” to their comments is amusing. The presidential hopefuls quickly recognized that the right to choose may not be the best policy for the public health of American citizens. Refusing to vaccinate a child potentially harms the child and may harm others!
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.
The challenges in primary care are many, and one of increasing importance is what to say to vaccine refusers. After much debate and thoughtful discussion, my medical partner, Dr. Janet Casey at Legacy Pediatrics, decided that the practice would refuse to care for the refusers.
Over the years, I have accepted such patients into my practice and worked with them to gain their confidence and debunk the many myths about the safety of vaccination that are so visible on the Internet. The approach worked well, and by the time the children were 1 year of age, I cannot remember but a handful of parents who did not come around to realize that it was best to vaccinate. However, with the recent measles outbreak at Disneyland in California, pertussis at epidemic proportions in pockets of the United States and elsewhere in the world, and the antivaccine voices gaining more and more attention, I agree, it is time to take a stand.
When a family brings their unvaccinated or undervaccinated child into the waiting room of a physician’s practice, that family is potentially exposing others in that waiting room to serious infectious diseases – that is not fair. In the waiting room may well be a patient who is on chemotherapy or immunotherapy or otherwise immunocompromised, and he relies on the “herd immunity” achieved by vaccinations of those who can safely be vaccinated for individual protection and public health. Those patients who have weakened immune systems did not choose to have their medical condition, whereas the vaccine refusers are choosing not to vaccinate their child (or typically themselves as well). And the reasons they are choosing not to vaccinate are based on misrepresentation of medical facts, fabrications of safety concerns, long ago disproven speculations by well-meaning and not so well-meaning physicians and scientists, pseudoscience published in pseudoscientific journals, and/or general distrust of the federal government that mandates vaccinations for the good of the public health.
My personal experience with vaccine scares dates back to a time when whole-cell pertussis vaccine was the only pertussis vaccine available. I was a medical student, resident, and then an infectious diseases fellow during the escalating debate about the significant side effects of vaccines. I joined in the chorus of voices questioning the need for clear data on the problem, and then the pursuit of a safer acellular pertussis vaccine. The physician community and the public were ready for change, and the National Institutes of Health took the lead in organizing multiple studies and clinical trials leading to eventual replacement of the whole cell pertussis vaccine with the current acellular vaccines.
Much more recently, at the request of National Institutes of Health, I led studies of the safety of thimerosal preservative in multidose vaccine vials that appeared in the Lancet (2002;360:1737-41); Pediatrics (2008;121:e208-14) and the Journal of Pediatrics (2009;155:495-9). Using the data from those three studies, the World Health Organization (WHO), the United Nations, the Institute of Medicine, and other organizations were able to see that the metabolism and elimination from the body of ethylmercury in thimerosal was dramatically faster, compared with methylmercury in fish. Therefore, the presumption of possible accumulation of mercury in the body of infants receiving vaccines from multidose vials when such vaccines were closely spaced was disproven by scientific data.
In plain language, there was never a known risk from thimerosal, but a premature, hurried decision was made to mandate removal of thimerosal from vaccines given to children in the United States and western Europe; thereby the myth lives on that thimerosal is not safe. Yet thimerosal is safe, and the WHO continues to advocate use of thimerosal in multidose vaccine vials. Nevertheless, I have been criticized personally on the Internet for this work. The accusation is that I, the rest of the scientists who participated in the study, and the NIH oversight were biased because our academic institutions had previously received funding from vaccine companies to perform clinical and translational research. I received many hate e-mails and even a death threat.
To close this column with a sense of humor, I suggest you Google the responses by U.S. presidential hopefuls on their stand with regard to vaccine refusers. The comments, then the reversal and “corrections” to their comments is amusing. The presidential hopefuls quickly recognized that the right to choose may not be the best policy for the public health of American citizens. Refusing to vaccinate a child potentially harms the child and may harm others!
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.
The challenges in primary care are many, and one of increasing importance is what to say to vaccine refusers. After much debate and thoughtful discussion, my medical partner, Dr. Janet Casey at Legacy Pediatrics, decided that the practice would refuse to care for the refusers.
Over the years, I have accepted such patients into my practice and worked with them to gain their confidence and debunk the many myths about the safety of vaccination that are so visible on the Internet. The approach worked well, and by the time the children were 1 year of age, I cannot remember but a handful of parents who did not come around to realize that it was best to vaccinate. However, with the recent measles outbreak at Disneyland in California, pertussis at epidemic proportions in pockets of the United States and elsewhere in the world, and the antivaccine voices gaining more and more attention, I agree, it is time to take a stand.
When a family brings their unvaccinated or undervaccinated child into the waiting room of a physician’s practice, that family is potentially exposing others in that waiting room to serious infectious diseases – that is not fair. In the waiting room may well be a patient who is on chemotherapy or immunotherapy or otherwise immunocompromised, and he relies on the “herd immunity” achieved by vaccinations of those who can safely be vaccinated for individual protection and public health. Those patients who have weakened immune systems did not choose to have their medical condition, whereas the vaccine refusers are choosing not to vaccinate their child (or typically themselves as well). And the reasons they are choosing not to vaccinate are based on misrepresentation of medical facts, fabrications of safety concerns, long ago disproven speculations by well-meaning and not so well-meaning physicians and scientists, pseudoscience published in pseudoscientific journals, and/or general distrust of the federal government that mandates vaccinations for the good of the public health.
My personal experience with vaccine scares dates back to a time when whole-cell pertussis vaccine was the only pertussis vaccine available. I was a medical student, resident, and then an infectious diseases fellow during the escalating debate about the significant side effects of vaccines. I joined in the chorus of voices questioning the need for clear data on the problem, and then the pursuit of a safer acellular pertussis vaccine. The physician community and the public were ready for change, and the National Institutes of Health took the lead in organizing multiple studies and clinical trials leading to eventual replacement of the whole cell pertussis vaccine with the current acellular vaccines.
Much more recently, at the request of National Institutes of Health, I led studies of the safety of thimerosal preservative in multidose vaccine vials that appeared in the Lancet (2002;360:1737-41); Pediatrics (2008;121:e208-14) and the Journal of Pediatrics (2009;155:495-9). Using the data from those three studies, the World Health Organization (WHO), the United Nations, the Institute of Medicine, and other organizations were able to see that the metabolism and elimination from the body of ethylmercury in thimerosal was dramatically faster, compared with methylmercury in fish. Therefore, the presumption of possible accumulation of mercury in the body of infants receiving vaccines from multidose vials when such vaccines were closely spaced was disproven by scientific data.
In plain language, there was never a known risk from thimerosal, but a premature, hurried decision was made to mandate removal of thimerosal from vaccines given to children in the United States and western Europe; thereby the myth lives on that thimerosal is not safe. Yet thimerosal is safe, and the WHO continues to advocate use of thimerosal in multidose vaccine vials. Nevertheless, I have been criticized personally on the Internet for this work. The accusation is that I, the rest of the scientists who participated in the study, and the NIH oversight were biased because our academic institutions had previously received funding from vaccine companies to perform clinical and translational research. I received many hate e-mails and even a death threat.
To close this column with a sense of humor, I suggest you Google the responses by U.S. presidential hopefuls on their stand with regard to vaccine refusers. The comments, then the reversal and “corrections” to their comments is amusing. The presidential hopefuls quickly recognized that the right to choose may not be the best policy for the public health of American citizens. Refusing to vaccinate a child potentially harms the child and may harm others!
Dr. Pichichero, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no relevant financial disclosures. E-mail him at pdnews@frontlinemedcom.com.
