WhiteCoat

Archive for the ‘Health’ Category

Could Medco Equal “Deadco”?

Thursday, July 8th, 2010

After seeing Mrs. WhiteCoat argue on the phone with Medco representatives for 20 minutes about why one of her 80+ year old patients hadn’t received her medicine despite three lost faxes to Medco, I had to write this post to let the public know what is going on with some mail order pharmacies.

If you’re like most Americans, you want to try to save some money. One of the ways that patients can save money is by cutting prescription costs.

Enter Medco. Medco is a mail-order pharmacy that receives prescriptions by mail or by facsimile and then sends patients their prescriptions by mail. Often, the prescriptions are for a three month supply of medications. By having warehouses instead of multiple “brick and mortar” retail buildings, Medco can save costs and presumably undercut the competition. An analogy might be that Medco is the “Netflix” of the pharmaceutical industry.

With the cheap prices come problems, though.

We probably see a couple of patients a month in the emergency department who have run out of medications because their shipment from Medco or some other mail order pharmacy hasn’t arrived. Most of the time the patients can’t get into see their family physicians and are just requesting a week or two worth of pills to “carry them over” until they get their shipment. Some patients try to split pills or take their medications every other day in order to hold out as long as they can.

Mrs. WhiteCoat is a family physician and she sees the other side of the Medco problem. When she faxes renewals for her patients’ prescriptions, her faxes are routinely lost. Doesn’t matter that she has a confirmation sheet. Medco makes her dig up the chart and re-send the renewal. Many times, she only finds out about the non-receipt of her faxes after her patients call her in a panic because they have called Medco’s customer service center, were told that no renewal was received, and are almost out of their medications.
Mrs. WhiteCoat also regularly gets faxes from Medco requesting that she change her patients’ prescriptions to a “preferred” medication. Unless she signs them and faxes them back, then calls to confirm with a pharmacist (not another physician) that patients really need the medication she prescribed, Medco won’t release the prescription and the patients don’t get their medication.

What’s the big deal – it’s only 5 or 10 minutes, right? Wrong. Many times it is more. Not too long ago, Mrs. WhiteCoat’s nurse was on the phone for 80 minutes getting prescriptions straightened out for 4 patients. That was time that the nurse couldn’t help patients in Mrs. WhiteCoat’s office and represented a loss of almost an hour and a half of the nurse’s salary to Mrs. WhiteCoat. Even if it is only 5 minutes, if you multiply 5-10 minutes times hundreds of patients, you end up with a significant amount of time each month of phone tag, waiting on hold during uncompensated phone calls, and hoops to jump through – just to get your patients their medications.

The mail order pharmacies may actually cost patients more money in the long run. If patients can’t reach their physician and have to come to the emergency department or urgent care center when Medco doesn’t get them their prescriptions in time then they may have to pay a copay or other out of pocket expenses for the extra doctor visit because of Medco shenanigans.

So if there is a mix-up in paperwork … or if Medco conveniently doesn’t get the faxed prescription for a patient’s medications (even though the physician has a confirmation page showing that the fax went through successfully) … or if Medco pharmacists think another medication might be better for you than the one that your physician prescribed … you just might not get your medications before you run out.

If you don’t get your blood pressure medications and you have a stroke … well at least you saved a few bucks on your prescriptions – when you finally get them.

So a question for the attorneys: Suppose an insurer or employer’s health plan only allows their enrollees to get these mail order prescriptions. No prescriptions from local pharmacies or national chains allowed. Now suppose that a patient has a stroke because they didn’t get their medication refill in time.
Can the insurer or employer be held liable for contracting solely with a company that is suspect in its duties?

Treating Asthma on the Cheap

Wednesday, July 8th, 2009

For people who suffer from asthma, most treatment involves an “MDI” or “metered dose inhaler.”

I won’t get into all the specifics here, but many people don’t use inhalers correctly which, in turn, significantly decreases the effectiveness of the inhaler. Putting the inhaler in your mouth and actuating it causes a substantial proportion of the medicine to be sprayed either on your tongue, on the roof of your mouth, or on the back of your throat. Ideally, patients should hold the inhaler 2 inches (2-3 finger breadths) in front of their mouth, open their mouth, actuate the inhaler, and then inhale deeply – with their mouth still open. Looks dorky, but that is what gets the most medications into your lungs. Often patients have difficulty coordinating the actions.
Here is a link describing proper MDI use.
aeroch6
Enter the spacer device. The spacer is a hollow chamber that fits on the end of a metered dose inhaler. The dose of medicine is sprayed into the chamber where it forms a mist. The patient then inhales the medicine from the other end of the inhaler so the particles get deeper into the lungs. Here’s a link about use of spacer devices. Use of a spacer device can increase the amount of medication delivered to the lungs by 300%.

While a spacer device can make you better, they’re expensive. You can get them from Canada for $65. In the US, they’re more like $80 to $100. If you lose them or they crack, you’re out another $100 to replace them.

So a patient came to the ED and was having trouble controlling her asthma. I recommended a spacer device to help her – in addition to adding steroids to her regimen. She told me that other doctors had recommended a spacer, but that money was tight and she couldn’t afford one.

Spacer Device So I MacGyvered a spacer device out of the water bottle she had sitting on the bed next to her. Basically, I used a pair of scissors to cut a hole in the bottom of the bottle that would just fit the end of the MDI (this is another version I made at home where the hole is a little too big).

This obviously isn’t an ideal device. Some of the medication will be deposited on the ribbed sides of the bottle. It’s probably a little bigger than it should be as well. But even if it doubles the amount of medication getting into the patient’s lungs, it’s better than using nothing at all.

It would be an interesting study to determine the amount of medication delivered via traditional spacer versus this jury-rigged version. If it helps keep patients breathing, it’s worth it.

UPDATE JULY 18, 2009
Thanks to the research from Allergy Notes! There were a couple of published studies showing no statistical difference between the use of homemade spacers and commercial devices.
See this Cochrane review
Also see this study in Lancet showing “a conventional spacer and sealed 500 mL plastic bottle produced similar bronchodilation, an unsealed bottle gave intermediate improvement in lung function, and a polystyrene cup was least effective as a spacer for children with moderate to severe airways obstruction.”

Mesothelioma

Sunday, May 24th, 2009

The following is a guest post by Richard Moyle.

Mesothelioma Often Mistaken for Less Serious Ailments

Mesothelioma is a type of cancer that affects the lining of organs, most often the lungs (pleural) but sometimes the stomach (peritoneal) or even the heart (pericardial). The only known cause of malignant mesothelioma is exposure to a toxic mineral known as asbestos. [Editor's note: Asbestos can be contained in such materials as insulators, furnace/pipe coverings, fireproof gloves, brake linings, and asbestos cement products. Additionally, significant occupational exposures to asbestos can occur from building demolition and mining].

Unfortunately, this type of cancer is rarely diagnosed early enough for treatment to be effective. There are two reasons for this. First, mesothelioma has a very long latency period and symptoms do not begin to show until about 25 to 50 years after exposure. Second, early symptoms and warning signs of the disease are very non-specific and often resemble symptoms of other conditions that are less serious. For example, the early symptoms of pleural mesothelioma may be mistaken for influenza or pneumonia, and this can result in misdiagnosis.

In most cases this misdiagnosis is by no means the doctor’s fault. If someone comes into an emergency room complaining of shortness of breath or painful breathing, mesothelioma is probably not one of the things that an emergency physician might suspect. Unless the doctor is informed of any previous asbestos exposure, he obviously has no reason to believe someone is suffering from an asbestos-related disease. If you have any of the following symptoms and you are aware that you have been exposed to asbestos in the past, it is very important that you inform your doctor:

  • Persistent dry or raspy cough (typically non-productive, meaning there is little or no phlegm)

  • Coughing up blood (hemoptysis)

  • Difficulty in swallowing (dysphagia)

  • Night sweats or fever

  • Unexplained weight loss of 10 percent or more

  • Fatigue

  • Persistent pain in the chest or rib area, or painful breathing

  • Shortness of breath (dyspnea) that occurs even when at rest

  • The appearance of lumps under the skin on the chest

Mesothelioma can only be officially diagnosed after a series of imaging, blood and tissue tests have been performed. Statistics show that most mesothelioma patients are diagnosed within 3 to 6 months after their first doctor visit with complaints about breathing problems or chest and abdominal pain.

If you are diagnosed with mesothelioma, your doctor will recommend an “oncologist” (a cancer doctor), who is well-versed in treating the disease and will help determine the best options for treatment.

More information about mesothelioma is available from the National Cancer Institute and from the Mayo Clinic.

Do As I Say …

Thursday, May 21st, 2009

Pediatricians hate treating kids for diarrhea.

The theory is that if you give children medications to slow down the diarrhea, that any infectious organism in the colon will have more time to multiply, will overgrow, and will, in turn, worsen the infection.

When children come in with diarrhea, they’re miserable, their parents are miserable, and they just want some help to feel better. Unfortunately, there’s not much on the market for treating diarrhea in children aside from probiotics or antibiotics in certain cases. Imodium elixir has dosing guidelines for kids, but many doctors shy away from recommending it. The goal is to use Oral Rehydration Therapy to get more in the mouth than comes out the other end.

Ditto for vomiting. Emetrol may help and is over the counter, but is essentially glorified sugar water. The only other medications to treat vomiting in children are prescription meds. Even the number of available prescription antiemetic medications has been narrowed considerably. Many pediatricians do not like giving children antiemetic medications unless children are dehydrated because there is a risk of “side effects” (although this study suggests otherwise, as does this Cochrane review). By the way, the “side effects” argument was the same one that pediatricians used to get most children’s cold medications taken off the market.

Here’s one About.com article on treating vomiting and diarrhea in kids.

One pediatrician on staff intermittently raises hell during medical staff meetings because emergency physicians have the gall to give children medications to treat diarrhea and vomiting. He repeatedly suggests that the ED docs “read up on” treatment of vomiting and diarrhea.

With a run on gastroenteritis in the community, this same pediatrician apparently thinks that vomiting and diarrhea of less than one day’s duration are impending emergencies. When parents are asked why what prompted them to bring their kids in for evaluation of diarrhea, they repeatedly say that they called the pediatrician and were told to go to the emergency department.

Because we aren’t supposed to give medications for vomiting or for diarrhea in children who are not dehydrated, I am now making it a habit to call the pediatrician when patients arrive – to let him know they got there and to ask what he wants me to do in the ED. I also call when the patients are discharged to let him know I have told them to follow up in the office tomorrow to make sure that they still aren’t dehydrated.

Kind of feel bad when we keep waking him up in the middle of the night for multiple patients – especially after being called by the parents as well, but through our conscientiousness, I’m hopeful that he will give the ED a better review during the next medical staff meeting.

You’re Full of …

Wednesday, May 20th, 2009

Literally. See for yourself.
All the whitish stuff in the middle of the picture from his upper abdomen to the base of his pelvis is stool.
This poor fellow had to have much of his colon removed and needed a colostomy.
Fortunately, he is doing much better postoperatively.

stool-impaction-ct-scout

Newest Crime: “DWT”

Monday, May 18th, 2009

texting-while-driving-foolSeveral events came together in a weird way confirming to me that this post just needed to be written.

The picture at the right was taken of the driver in a delivery van that swerved over the midline – in the rain – while I was driving down the street behind him. We got to a light and he has his little phone in his hand texting away.

Then, an aunt of mine (by marriage) and three people in her vehicle, including the 17 year old driver, were recently killed in a terrible car accident.  Two others in the vehicle survived with serious injuries. They were traveling late at night and initially police thought that the driver fell asleep at the wheel. After speaking with one of the survivors, they discovered that she was trying to send a text message to a friend while driving down the road at 70 MPH.

I’ve seen my share of serious injuries in the ED resulting from accident victims doing the same thing.

On a news feed that I get, one of the articles this morning was about how the Missouri legislature just passed a bill outlawing those 21 and younger from “Driving While Texting” or “DWT.”

The comment section to the article has many people arguing that there is too much government regulation already. One commenter writes “What’s next? Picking your nose, eating a cheese burger, changing cd’s, maybe even yelling at your kids? And don’t you dare look at the navigation unit that comes from the factory installed on your car!” Some argued that the law needed to be expanded to everyone, not just those less than 21 years old, while others argued that such a law would be unenforceable.

It’s tempting to say that if people who “drive while texting” die or are maimed in a car accident, their injuries are “punishment enough.” Those sentiments don’t take into account the financial toll that their medical care takes upon the families or the government. Nor do those sentiments account for the injuries that distracted drivers cause to other parties when they broadside a minivan because they’re too wrapped up in their text messaging.

For crying out loud, if you’re going to communicate while driving, just call someone already.

Hey BFF … the close up view of a tractor trailer bearing down on your windshield at 70 MPH  isn’t a “LOL” moment … U KNOW?

What Do Hypertension and Ulcers Have In Common?

Thursday, May 14th, 2009

Answer: They were both thought to be due to “stress” at one point, but were later linked to infectious processes.

Most ulcers are now known to be caused by Helicobacter pylori, or H. pylori for short.

Now a new study in the Public Library of Science shows that hypertension may be caused by cytomegalovirus infections. CMV apparently increases inflammation in the blood vessel walls and increases the secretion of both renin and angiotensin II – both known to contribute to hypertension. CMV infection plus a high cholesterol diet also caused atherosclerosis in the aorta while CMV infection without high cholesterol did not.

Any pharmaceutical company that has a hypertension medication on patent is not going to be happy about this study. Then again, Roche stock is probably going to make a nice little jump as Roche makes ganciclovir and valganciclovir – both medications used to treat CMV. Roche also makes a little-known drug called Tamiflu.

Wouldn’t it be wild if all the hypertensive medications were rendered useless by an antiviral drug?

I’d be interested to see whether HIV patients on chronic treatment for CMV retinitis are any less likely to have hypertension.

Additional news stories from:
Reuters, Medpage Today, and the Associated Press

When Pigs Fly

Tuesday, April 28th, 2009

flying-pig-weathervane[I'm sure that everyone will be tired of hearing about the swine flu by next week, but I'll leave this post stuck to the top of the blog for a little while and will add links to the bottom so that those who are looking for more information can easily access it.]

Who ever thought that this phrase might be applicable to everyday life?

With the current swine flu having genetic components from N. American swine influenza A, European/Asian swine influenza A, N. American avian influenza, and N. American human influenza, it just goes to show you …

I’m not going to add any more pithy statements, but did want to give everyone a few resources to look at for more information about the swine flu.

First, EP Monthly just posted an excellent article about swine flu here. There are also several pertinent questions in the comments section of the article that are worth reading. One commenter notes that there is no Tamiflu left in the pharmacies in his city. The article will be updated when more information becomes available, so check back if you have questions or even consider posting a question in the comments section yourself.

Second, the government site for information regarding swine flu is here.

WebMD also has a swine flu center that is updated regularly.

UPDATE APRIL 29, 2009
Swine flu described as “uncontainable” – USA Today
First US fatality from swine flu is 23 month old Texas child – AP #1, AP #2
Vaccines for swine flu likely not available until November – NY Times.com, LA Times
Do masks help prevent swine flu? ABC Houston
Mexican government shuts all nonessential functions to fight flu – MSNBC

UPDATE APRIL 30, 2009
Thanks to James for this link – http://doihaveswineflu.org/
Don’t run to the ED with runny nose and cough – El Paso Times
“No safer place than home to avoid being infected with flu virus” – Felipe Calderon

UPDATE MAY 1, 2009
Hospitals swamped amid flu fear – LA Times
[quote from article: "The pressure has been to close excess beds and get lean," said Columbia's Redlener. "Lean is not your friend in a pandemic."]
Lack of funding affects hospital’s ability to respond to prolonged flu outbreak – San Jose Mercury News
Press release from American College of Emergency Physicians regarding swine flu – ACEP.org
Caring for influenza at home – CDC.gov
US sends Tamiflu to Mexico, purchases 13 million more courses of treatment from manufacturers – Reuters
More Tamiflu use = higher likelihood Tamiflu resistance – Bloomberg.com
—–

Assuming the Worst

Monday, March 23rd, 2009

rotor-brake-caliper-brake-padsYesterday happened to be the day that the brakes went bad on my truck.

For the past week I’d been getting the “squeeking” sound when I put on the brakes and had planned to replace the pads today, but yesterday while driving home from a trip, there was the dreaded “grinding” metal-on-metal sound that means your rotors are getting torn up. I just had new rotors put on my truck about 8 months ago, so I didn’t want to put off changing the brake pads any longer.

I stopped at the auto parts supply store and bought brake pads on the way home.

Before I go further, I  have to admit that I know enough about cars to get by, but I’m nowhere near a mechanic. I do my own tune ups, change my oil, change my brakes, and even do my own wiring for stereos. When things get more complicated than that, I leave it to the experts. Changing belts and replacing major parts is out of my league. When the dealer replaced my rotors, it cost me more than $600. What can you do? You have to pay it.

I put the truck up on a jack and pulled off the wheel, exposing the brake caliper (upper left) and the rotor (round shiny thing in center of picture). After I pulled off the brake calipers, sure enough, the brake pads were worn flat. You can see the brake pad sitting on the floor at the bottom of the picture.

Then I noticed something that got me angry.

There are two screw holes (red arrows) on the rotor that hold the rotor in place. The screws were missing and the rotor was flopping back and forth on the wheel hub.
The damn dealer forgot to attach the rotor to the wheel hub when it replaced the rotor.
I pulled off the other wheel. Same thing! The rotor was just flopping there.

What if the rotors came off while we were driving home earlier in the day? My family would have been a statistic. We’d all be dead.
I called the auto supply store I usually go to. They don’t stock bolts like that. “Why wouldn’t they replace them when they changed the rotor?” the parts guy asked.
I called several other supply shops. None of them stock bolts like that, either. The last store I called told me that I’d have to call the dealer in the morning before my car would be safe to drive.
Every call I made caused me to get more angry.
That’s it.
I’m putting the name of the dealer on my blog and blasting them. Damn them. I’m calling the better business bureau. I’m writing a letter of complaint to the head of the dealership and I’m sending a copy of the letter to the newspaper. How the hell could these IDIOTS risk the lives of my family by just slapping new rotors on my truck without securing them to the wheel hub?
A couple of more phone calls to parts stores that were closed got me even more ticked off. The dealer would probably have to special order the bolts and I wouldn’t be able to drive my truck for a week.
I was fuming.

Then I found a parts store about 25 miles away that might have the bolts in stock. I was in luck. The guy I spoke to put me on hold while the manager of the parts department came to the phone.
“What can I get for you?” he asked.
“I need two sets of bolts that hold the rotors to the wheel hub for an ’04 Chevy Blazer.”
“You mean lug nuts?”
“No. The rotor itself has two threaded holes on it. I’m assuming that bolts go through those holes and attach the rotor to the wheel hub. Right now, when I pull the brake calipers off, the rotor is just flopping around on the wheel hub.”
“Yeah, but it’s supposed to be like that.”
“Are you serious? The rotor is just supposed to flop around on the wheel? What if it slips?”
“Bud, I was a mechanic for 20 years. Once you put the wheel back on and tighten up the lug nuts, the rotor is locked in place. It won’t move a bit. You don’t need the screws to hold the rotor in place. The lug nuts do that.”
“Are you sure?”
“Every mechanic I know has been doing it like that for as long as I can remember. A lot of car companies don’t even make bolts to hold the rotors in place. Besides – sometimes you get rotors that aren’t made by the manufacturer and they don’t even have the holes in them. Sometimes the holes don’t line up with the holes in the wheel hub. Then what do you do?”
“Makes sense. I just don’t want the brakes to go or the wheel to pop off or anything like that.”
“You’ve been driving around on them for how long without a problem?”
“A long time … OK, I get your point. I’ll have to bring you in a six-pack for putting my mind at ease. Thanks.”

I’m sure he hung up the phone and thought to himself “what an idiot.” Even so, I’m making it a point to go to his shop in the future because I value his opinion, and instead of trying to sell me something, he helped me understand the problem.

Then I had a “lightbulb moment.”

What I just went through is exactly what many patients must go through after having a bad outcome from medical treatment.
Patients accumulate knowledge about medical problems from all kinds of sources. Maybe they read things off the internet. Maybe they hear things from neighbors or relatives who had similar problems. But, just like my experiences with my brakes, the information that patients accumulate about their medical treatment isn’t always correct.

I know very little about replacing a rotor, and when something wasn’t the way I expected it to be, I assumed the worst – even though the work was done right. I spoke to several people at auto parts stores who apparently knew as little about replacing rotors as I did. Their uninformed comments got me so mad that I wanted revenge.

My problem was that I assumed I knew enough about brakes and rotors to make a decision about the competency of an expert I hired to fix my truck. When I doubted his competency, I then tried to confirm my suspicions with others whom I assumed knew more about the topic than I did. But I never went to the expert who did the work. In fact, I never asked any expert. I just assumed the worst. Based on my lack of knowledge I was ready to blast an expert who did appropriate work.

When there is a bad medical outcome, or even when there is the perception of a bad medical outcome, the natural tendency is for patients to assume the worst. The patient with the bad outcome then discusses his experience with others, and may be provided with misinformation. Enough misinformation and pretty soon the patient is all worked up – maybe for no reason.

Not saying that bad outcomes never occur from someone doing something wrong – whether talking about car parts or surgical treatment. Just saying to make sure you’re well informed before making that decision.

What did I learn from my experience?
1. Don’t jump to conclusions.
2. Experience is what makes an expert an expert.
3. There would be a lot less acrimony in this world if people would just communicate better.

Killing Lice …

Thursday, February 26th, 2009

… is easier using over the counter products such as Nix along with a fine-toothed comb to get rid of nits.

Dousing your head with gasoline isn’t the way to go. Aside from causing a host of physical symptoms, the fumes from the gasoline can also explode and burn you … badly.

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