An article written by two physicians in Time magazine questions whether we should blame doctors for the large number of chronic pain patients and the abuse of prescription pain medications.

There are two frames of reference to this article.

First, no one can argue that prescriptions for pain medications in this country are excessive. The article notes that in 2011, “enough hydrocodone was prescribed to medicate every American around the clock for a month.”

As both authors are emergency physicians, the end of their article notes that “we must stop fearing patient-satisfaction surveys and talk honestly to our patients about pain.”

Ask most emergency physicians and they will tell you that satisfaction surveys pressure physicians to overprescribe multiple medications, including antibiotics and opiates.

But where do all the medications go?

Note how many commenters to the article are upset because they or their family members are having a difficult time obtaining pain medications for their chronic medical problems.

Doctors are becoming increasingly aware that if they prescribe pain medications to a patient who dies, there’s a decent chance they’ll be dragged through administrative and legal proceedings regarding the death. So doctors then learn to fear the bad outcome and then take steps to avoid the bad outcome. Doctors can’t get sued if they don’t prescribe the pain medications.

Patients in legitimate chronic pain are paying the price – and it isn’t just in the emergency department, either. From the comments:

“their physician won’t see them anymore because they need stronger pain medication”
“His GP won’t prescribe, his GI won’t prescribe, the Pain Clinic keeps trying to push him into treatments that DO NOT WORK for his disease”
“the ER staff will still stand around and pretend like opioids don’t exist and it’s okay to let the patient lay there in pain”

Reminds me of a post I wrote nearly 5 years ago. Only this time, the solutions that our governments are proposing seem to be adding to the problem.

When we vilify, sue, and criminalize doctors whose patients die from medication overdoses, fewer and fewer doctors are going to be willing to prescribe pain medications.

I’m predicting that we’re going to see a downward trend in the amount of pain medications prescribed. The threat of incarceration is going to outweigh the threat of bad satisfaction scores.

And we’ll all be “safer” through more regulations, bad press, and blaming physicians for the bad apples … right?

Photo credit and further story at http://www.inquisitr.com

Medical care for the morbidly obese is back on the radar.

Today this blog got several inbound clicks from a site where a bunch of apparent doctor haters have used one of my blog posts and the comments to the post as an example of how much the medical profession allegedly likes to bestow shame upon others. It seems that the discussion we had regarding whether it is ever acceptable to refuse medical care to morbidly obese patients was something that Ms. Marianne’s readers were cautioned that they may not be able to “stomach.”

The author and most of the people who commented to her article seem to believe that they have the right to demand that any doctor at any time must provide any type of services to them that they demand. Whether or not the doctor is comfortable providing those services or whether the doctor even has the knowledge and training to provide those services is irrelevant. Any doctor who doesn’t agree to their demands is hated and publicly shamed. This doctor who chose not to treat patients weighing more than 200 pounds was one example of their wrath.

I left a comment to Marianne’s rant back when she first posted it.
I don’t remember the comment verbatim, but the gist of my comment was that there are specialists for a plethora of conditions who provide care to patients when other providers are uncomfortable caring for those conditions – HIV, diabetes, organ transplants, ophthalmology, etc. Why shouldn’t doctors be able to refer obese patients to other physicians more experienced in caring for obese patients?
In addition, there is no “right” to force any person to provide you with any services against their will. The Thirteenth Amendment to the Constitution addressed that.
Finally, I noted that when there is a bad outcome related to a patient’s obesity, one of the first things that a plaintiff’s attorney will allege is that the patient should have been referred somewhere else.
My comment was never approved. Non-conforming, I suppose.

Today there also happened to be an article in the NY Post – linked by the Drudge Report – about how a morbidly obese woman with multiple health problems traveled to Hungary for a month-long stay in their family vacation home. When she tried to board a flight back to New York to resume her medical treatment, the airline refused her because she had gained water weight and could not be safely strapped into three seats. The airline tried to make alternate arrangements for the patient’s travel back to the US, but those plans also fell through due to the patient’s size.
There was no mention that the woman ever went to a hospital for care of her medical problems while trying to secure travel back to the US. Both the patient and her husband were quoted as saying that they “didn’t trust” doctors in Hungary.
Nine days after first attempting to return to the US, the woman died.

Difficult situation. Comments to the article were mixed. Some people blamed the patient for allowing herself to become so obese. Others blamed the airline because it was able to get the patient to Hungary and then left her stranded there.

This case illustrates the point that I was trying to make in my previous post about providing medical care to morbidly obese patients. At some point, the safety and well-being of the patient and of others must be taken into account when deciding whether to provide care. These decisions are made all the time in medicine. A patient with severe lung disease may be deemed too great a risk for surgery. The doctors aren’t “discriminating” against people with lung disease, they are making a decision that the risks of surgery are too great given the patient’s condition. Some orthopedists choose not to perform knee or hip replacements in morbidly obese patients. Again, not “discrimination,” but rather the significantly increased risk of complications in morbidly obese patients.
In the Hungarian patient’s situation, what if the patient suffered an injury on the plane because she wasn’t able to be properly restrained? What if the patient had a medical emergency and died on the plane over the Atlantic Ocean because of her untreated medical conditions? Would these same people then point fingers at the airline for allowing the patient to fly in the first place?
Rather than engage in a rational discussion about the issues, some people would rather sensationalize, cry discrimination, and call names.

Something about the patient’s situation just doesn’t make sense to me.
I question how much “water weight” the patient gained during her vacation.
I also wonder whether the patient and her husband checked into the flight restrictions that might be imposed on the patient before taking their trip.
And why it was appropriate for the patient and her husband to discriminate against all doctors available to provide them medical care in Hungary solely because of the doctors’ national heritage?

Apparently “doctor hating” is still socially acceptable.

UPDATE
See additional stories and pictures here:
http://www.inquisitr.com/412995/sick-obese-woman-dies-after-airlines-turn-her-away/
http://gothamist.com/2012/11/26/overweight_woman_dies_in_hungary_af.php
http://www.upi.com/Top_News/US/2012/11/26/Woman-dies-after-airline-turned-her-away/UPI-70441353953221/

Influenza has arrived.

Some Georgia emergency departments are seeing a 25-30% increase in volumes due to people seeking care for influenza or influenza-like illness.

According to the CDC web site, there is good match between vaccines and the circulating virus strains this year. H1N1 virus strain not being seen much. H3N2 is the predominant Influenza A strain while “Yamagata lineage” is the predominant Influenza B strain in circulation. Note that there is one Influenza B strain circulating that was NOT contained in the vaccine – the “Victoria lineage” which accounts for about 15% of the total samples tested.
For an interesting look into how influenza vaccines are created each year, see this link.

It’s not too late to get vaccinated, but realize that vaccination takes about 1-2 weeks to generate an immune response in your system before it becomes effective.

One side note, there are some medications which may shorten the course of influenza when taken early in the course of the disease. One 2012 Cochrane review questioned the effectiveness of neuraminidase inhibitors (Tamiflu and Relenza) because “60% of patient data from phase III treatment trials of [Tamiflu] have never been published” and because the company that produces Tamiflu – Roche – reportedly ignored five different requests from the researchers to release the information in those studies.
According to the CDC site above, so far there is no resistance to the neuraminidase inhibitors with any of the influenza strains. There is high resistance to the less expensive amantadines in all influenza A samples (influenza B is not sensitive to amantadines).
In other words, if you get the flu, taking amantadine (Symmetrel) or rimantadine (Flumadine) would be just as effective as taking a “ZeePack” (Azithromycin) or as taking red jelly beans in making you feel better.
I’m personally not a big fan of Tamiflu and Relenza. I’ll discuss the above with patients who have influenza, and afterwards if people want to pay $50-$120 for medications that may make them feel better and may shorten the course of the disease by 12-24 hours, I’ll write them the prescription. PT Barnum philosophy in my book.
In our state, Tamiflu and Relenza aren’t on the Medicaid formulary – only amantadine. You’d be surprised how many people demand amantadine prescriptions so that they can take something to help with their symptoms – even though it has little or no effectiveness against the circulating virus strains. Seems that no one cares about amantadine’s side effects. They just want a pill.
I’d prescribe red jelly beans instead, but those aren’t on Medicaid’s formulary, either.
Good thing those folks have insurance, though.

Finally, if you want an interesting influenza anecdote to start up a conversation at parties, this year scientists discovered a new influenza virus that is entirely different from all known influenza A viruses. The hemagglutinin portion of the virus (the “H” part of the influenza designation in “H1N1”, for example) was dubbed H17. The neuraminidase portion of the virus (the “N” in the H1N1 designation) hasn’t been determined. Researchers weren’t able to grow the new influenza virus in any of the traditional methods and believe that the virus would require significant mutations before it is able to infect humans. Just to be safe, though, stay away from Guatemalan fruit bats – which were the reservoir for the new virus.

Here’s a medical conundrum for all of you faithful viewers of “House” out there.

I’m throwing this out there because I have never seen it before. I did some internet searching and think that I came up with the answer (.pdf file) but I’m not positive.

The basic history is that the patient is a bed-bound nursing home resident who has had a conic Foley catheter. The nursing home stated that the urine had started to turn purple over the past 2 weeks. The degree of purple discoloration got more and less, but never went away. It had become particularly bad recently, prompting the call to the ambulance. Notice how even the tubing is purple-colored.

Labs and a UA were sent from the nursing home a week prior and showed some minor renal insufficiency, but were otherwise pretty normal (except for urine color).

Labs done in the ED showed continued renal insufficiency, a mildly elevated WBC count and a UTI. Remember – the patient had no UTI on a UA performed one week prior while she was still having symptoms.

So what is causing the Case of the Purple Urine?

By the way – if you want to use this picture for other purposes, just click on it for a larger version or e-mail me and I’ll send you the high-res version.

For those medical practitioners that don’t usually read EP Monthly, there are always good articles from some of the top names in emergency medicine. Lately, there have been several articles published that are exceptionally good.

Rick Bukata has a thought-provoking article about management of simple abscesses. Definitely worth a read. The bottom line is that most abscesses resolve just fine after they are lanced (medical terminology = Incision and Drainage or “I +D”). A majority of abscesses – 50 to 66% are due to MRSA (methicillin resistant staph aureus – a “superbug”). The organisms causing the abscesses were resistant to the antibiotics prescribed in some if the studies Rick cited, but the cure rates were still quite high – and were similar to those patients taking no antibiotics at all. Kind of interesting to consider that by giving antibiotics to patients with abscesses, we aren’t helping the patients and we could be increasing the prevalence of the same organisms we’re trying to eradicate.
So why do doctors keep prescribing antibiotics to patients with abscesses? I’m going to venture a few guesses:
1. They don’t keep up with the literature. Old habits die hard.
2. Many patients expect them. If patients expect antibiotics and don’t get them, then they complain to administration or give us bad Press Ganey scores. This is one of those perverse situations in which outside influences can affect proper medical care.
3. If there is a bad outcome, attorneys and journalists will sensationalize the case and fault the doctor for not giving antibiotics. Call it defensive medicine. It is a lot easier to fault someone for doing nothing than to fault them for doing something – even if that something is of marginal benefit.

Speaking about antibiotic use, an article from a few months ago by David Neuman (who works with Graham Walker and others over at theNNT.com – an excellent resource for clinicians) explores whether antibiotics are useful in preventing infections after mammalian bites and in treating “bronchitis”. Some of the results will surprise you, some of them shouldn’t surprise you. One interesting factoid: Out of 100 patients prescribed antibiotics for “bronchitis,” none receive any benefit and about three of them are harmed by the antibiotics themselves. I’d say that every one of the patients receiving antibiotics is harmed. They pay a lot of money for medicine that doesn’t do a thing to help them.

News you can use about pediatric appendicitis from Ghazala Q. Sharieff, including scoring systems, ways to predict severity, and potential testing to use if ultrasound is equivocal.

This blog gets a lot search engines hits from people (presumably physicians) who are looking for the best states in which to practice medicine. Many of the hits go to a previous post on this topic here.

Medscape recently came out with a new set of recommendations based on research done by Shelly Reese, a freelance writer from Cincinnati. Based on Shelly’s research, Medscape recommends the following states:

New Hampshire – for its low unemployment, high insurance coverage, and no sales tax or state income tax. On the down side, compensation is comparatively low and winters in New Hampshire reportedly suck.

Utah – for its high rate of employer-based insurance, low physician density, and low cost of living. With the low cost of living is a lower than average compensation as well.

Idaho – for its low physician density, low liability insurance costs, and low cost of living. However, the state income tax tops out at 7.8%.

Georgia – for favorable compensation, lower physician density, and good lifestyle. However, there are more uninsured patients and malpractice coverage is comparatively more expensive in Georgia.

Virginia – for low cost of living, higher number of insured patients, and low malpractice insurance costs. These “pros” are offset by lower average income.

South Dakota – for low malpractice costs, low physician density, and no state income tax. Down sides are the less than desirable weather.

South Dakota was the only state that made both this list and the previous list from 2010.

Looking to avoid the WORST states in which to practice medicine?

No surprise that FLORIDA is on the list of worst states to practice medicine. You can see my Top 10 Reasons Not to Practice Medicine in Florida link in the upper right corner of this blog explaining why. Also making the list are Washington DC, Illinois, Connecticut, Arizona, and Alaska. Flip through the slide show on Medscape to see why …