Where's the Outrage?

Just over two weeks ago I took my first trip down to Galveston since Hurricane Ike. Ike hit in mid-September.

Above and below are pictures I took in Galveston. One is of a boat still out of the water. The other is of a very damaged pier. You can explore the online edition of the Galveston County Daily News to get some sense of life on the island today.

The upshot of what I saw in Galveston is that the outward damage to buildings could have been much worse, but that many homes and business places were flooded with sea water and need much work before they can be used again.

The fact that gets lost is that Galveston was an economic disaster zone before the hurricane. The poverty rate on the island has always been high. In 2007, 20.6% of people living in Galveston lived in poverty. This is even higher than the appalling 16.3% rate for all Texas. 

With massive layoffs at the University of Texas Medical Branch in recent days, Galveston has become even more of a disaster zone. UTMB is the largest employer in Galveston. 8,000 of its 12,000 employees live in Galveston. 3,000 people are being let go with this round of layoffs. Galveston had a pre-hurricane population of just over 50,000.

It’s a trick when we are told the hurricane was a unique disaster for Galveston. The trick is that disaster conditions that merit a special response come only every so often, and the rest of time it is business as usual.     

Of course in Texas, we do things a bit differently. The prevailing ethos under both Democratic and Republican political control in Texas has often been to kick a guy when he is down. The layoffs at UTMB, under the pretense of losses sustained since the hurricane, is a fine example of this creed. The fact of an actually acknowledged disaster was just the right time for the huge job cuts. 

Oh, for the malignant neglect of better days!      

The downsizing of UTMB began before the storm. The number of beds and services for the uninsured were already being cut.  You can take what the University of Texas Board of Regents says about the cuts being a result of the hurricane as false. They want to chop down the size of UTMB and leave Galveston, of all things, high and dry, when it comes to places to work on the island.  

Galveston is one of the founding communities of Texas. It’s history runs many years before that of most of the rest of Texas. I’m not going to pretend I have the solution to Galveston’s problems. A good starting point might be to see Galveston as worth saving. And to realize that even with the Sea Wall, Galveston has long been underwater in many regards.     

Tags: Environment, Medical Ethics/Issues by Neil Aquino
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The right-wing talking heads have been whispering to American Jews that they can’t trust Senator Barack Obama. “Barack Obama doesn’t really support Israel,” they say. They have taken Obama’s statement on speaking with our enemies to mean that Obama would speak with Hamas, although he has never said that. Well, today Obama was in Boca Raton, Florida where tried to put all of these fears to rest. Obama promised an “unshakable commitment” to Israel. He was also hoping that his presidency can repair some of the damage in African-American and Jewish-American relationship. These problems date back to Jesse Jackson’s ill thought out statements over 25 years ago.

Finally, although it has been rumored for months, tomorrow is the day that Senator John McCain is suppose to release his medical records. Back in 2000, McCain was diagnosed with Malignant Melanoma of the face and arm. Were these two separate lesions? Was one lesion a primary and the other a secondary or metastatic lesion? The implications are significant. In 1993, McCain had a melanoma removed from his shoulder.

Now, I’m not a cancer surgeon, but I am a surgeon. In 2000, McCain had a return or recurrence of his cancer. If I’m not mistaken, metastatic melanoma can not be cured only treated. In my book, this would make him an extreme risk as a president.

Tags: Election 2008, Healthcare, Medical Ethics/Issues by ecthompson md
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About 10 years ago, I was working as an emergency room doctor at a small community hospital. A 25 year-old gentleman came in with a bump on his head. It seems that while he was working, he turned around and hit his head on a metal pole. The gentleman had a small goose egg in the middle of his forehead, otherwise known as a hematoma. I asked all of the important questions and the patient said “no” to all of them. I gave him all of the warnings of what to look for that would be cause for concern. Then, I wrote a prescription for pain and discharged him.

If you could have witnessed the scene that man put on in the emergency room. He complained that I didn’t know anything, that I was a quack. He said he was seriously injured and that I needed to do some tests.

The standard of care is to get a CT scan on all patients who experience a loss of consciousness. Most physicians do not want the scene that I described above. It is faster for them to order the CT scan, get the normal results back, then talk to the patient armed with a negative CT scan. Most patients come to the hospital with expectation; They want the physician’s time and they want tests. This is reality.

Also, the fear of lawsuits is real. A physician exam is subjective. A CT scan is objective (for the most part). It is something that you can show the jury that will save a physician’s butt.

There is a new AP article that suggests that insurance companies are taking a closer look at what scans need to be ordered. Look for the medical community to push back big time. The medical community may join with patient advocacy groups to take on the insurance companies. Physicians must be able examine their patients and discuss a course of action that will lead to a diagnosis. Insurance companies should not be allowed to insert themselves between the physicians and the patients (any more than they already are).

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From AP:

Insurance companies are taking a harder look at advanced medical scans like CT scans, citing spiraling costs and safety concerns. And some doctors agree there’s emerging evidence that these scans are being over-prescribed.

“Costs are soaring in this area, quality concerns are mounting and safety concerns are mounting,” said Karen Ignagni, chief executive officer of the trade group America’s Health Insurance Plan.

Health insurers are requiring more preauthorizations before patients can receive these scans, and setting other restrictions including mandating that the imaging equipment and medical staff operating it be credentialed in advance. (more…)

Tags: Medical Ethics/Issues by ecthompson md
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Re-Posted 

I thought that would introduce a new segment to Where’s the Outrage – medical ethics.

A 20 year old female presents to the ER.  She complains of feeling like somebody is trying to get into her head.  The patient looks scared and anxious.  Her eyes are darting back and forth.   Her speech is pressured and rapid.  You are the ER physician.  You run a battery of tests and conclude that the patient may be a danger to herself.  You ask her if she will be willing to come in the hospital for some treatment that you think will help her.  She agrees.  As soon as you walk out of the room, the patient is seen by the charge nurse trying to leave.

What should you, as the ER physician, do?

Tags: Ethics, Healthcare, Medical Ethics/Issues by ecthompson md
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The King Faisal Foundation has recognized Donald Trunkey, MD, and Basil Pruitt, MD for their accomplishments in trauma. Dr. Trunkey wrote a paper in the late 60′s showing the preventable deaths in LA County and suggested that trauma centers be developed. These trauma centers would be dedicated to taking care of the trauma patient. Over the last 20 years, trauma centers have been shown to reduce mortality and morbidity in trauma patients. Basil Pruitt, MD has spent most of his caring for the Burn patient. He has helped develop and standardize the treatment of the burn patient. Currently, Dr. Pruitt is the editor long-time editor of the Journal of Trauma.

Both Drs. Trunkey and Pruitt have been extremely productive in their academic life. Each publishing well over 250 scientific articles and book chapters. These are 2 outstanding surgeons. I congratulate both of them for their contributions to medicine.

Tags: Medical Ethics/Issues by ecthompson md
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A recent New York Times story reported that many people die in hospitals from cardiac arrest because hospital personnel do not reach them in time. And, also, because they are black and/or poor.

From the story—

In nearly a third of cases of sudden cardiac arrest in the hospital, the staff takes too long to respond, increasing the risk of brain damage and death, a new study finds.

In the real world, doctors and nurses do not always run fast enough. Expert guidelines say the shock should be given within two minutes after the heart stops, but the study found that it took longer in 30 percent of the cases.

The consequences were striking. When the defibrillation was delayed, only 22.2 percent of patients survived long enough to be discharged from the hospital, as opposed to 39.3 percent when the shock was given on time.

The study, being published Thursday in The New England Journal Of Medicine is the largest ever to look at what happened to patients with “shockable” abnormalities in heart rhythm, and to correlate their outcomes with the time it took to deliver the needed shock.

Delays were more likely in patients whose hearts stopped at night or on the weekend, who were admitted for noncardiac illnesses, in hospitals with fewer than 250 beds and in units without heart monitors.

Being black also increased the odds of a delay, but the researchers said this finding probably reflected the quality of hospitals in areas where most blacks live and are treated, rather than a decision by medical workers to drag their feet because of a patient’s race.

[Read more →]

Tags: Healthcare, Medical Ethics/Issues by Neil Aquino
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I have written on stem cell research several times.  I have supported stem cell research.  I have written about stem cell research in my book, A Letter to America.  This break through is very exciting BUT we have had breakthroughs before that haven’t worked out.  We had the South Korean scientist that reported a huge breakthrough in stem cell research only later did we find out that he fudged the data.  The reason that I believe that this isn’t another venture into left field is that 2 different research groups using 2 different methods have the same results.  Skins cells have been made to act like embryonic stem cells.

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From WaPo:

Researchers in Wisconsin and Japan said yesterday that they have turned ordinary human skin cells into what are effectively embryonic stem cells without using embryos or women’s eggs — the previously essential ingredients that have embroiled the medically promising field in a nearly decade-long political and ethical debate.

The ability to turn adult cells into embryo-like ones capable of morphing into virtually every kind of cell or tissue, described in two scientific journal articles yesterday, has been a major goal of researchers for years. In theory, it would allow people to grow personalized replacement parts for their bodies from their skin cells and give researchers a powerful means of understanding and treating diseases.  (more…)

Stem Cell breakthrough [ 2:56 ] Play Now | Play in Popup | Download

Tags: Medical Ethics/Issues, Science by ecthompson md
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The New York Times today reported the death of Dr. Eugene Saenger of Cincinnati. He was 90.

Dr. Saenger was a radiologist and expert on nuclear medicine who did Cold War era radiation experiments on poor folks and black folks in Cincinnati between 1960 and 1971.

While a University of Cincinnati English Professor named Martha Stephens made an effort to publicize this issue in the early 1970′s, the experiments gained the most attention in Cincinnati in the 1990′s. This was when other government Cold War experiments elsewhere in the country came under a renewed scrutiny.

In 2002, Professor Stephens published a book on the experiments called  The Treatment.

What Dr. Saenger did, was give people with cancer radiation over their entire bodies instead of just where the cancer was located. This despite evidence that existed at the time that such treatment would do more harm than good.

[Read more →]

Tags: Books, Medical Ethics/Issues, Race by Neil Aquino
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Very nice story on Elizabeth Edwards.

I waiting for the hateful venom to start spewing from the right.

I’ll have more on breast cancer later.

Countdown - Elizabeth Edwards [ 6:48 ] Play Now | Play in Popup | Download

Tags: Countdown, Healthcare, Medical Ethics/Issues by ecthompson md
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…to child of mother with tattoos. The story is here. And there is much discussion about it on the internets.

Dr. Gary Merrill, of Christian Medical Services, in Bakersfield, CA, is in private practice and has limits on who he will treat. Amongst the exclusionary criteria are presence of tattoos or body piercings.

I think that it is hardly a Christian principle to deny medical care to children because of the lifestyle choices of their parents. As a Catholic, I’m offended by the use of Christianity to justify this decision. As a pediatrician, I’m disgusted by any rationalizations for the denial of services to the most medically underserved portion of our population. As an earring-wearer, I’m offended by the thought process that leads to an assumption that I am a tool of the devil.

Yet his practice is not an emergency room and is not subject to EMTALA as a matter of routine obligations. His practice is a private practice, and unless he had a prior existing relationship with this patient, I think he is probably within his legal rights to make this decision.

And as much as I disagree with him, as much as I would never take my kids there for care, I defend his right to run his practice in whatever misguided fashion he desires.

I guess he gets my most recent nomination for Moron of the Week.

Tags: Medical Ethics/Issues by desertbug
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From LA Times: 

A sustained dose of RU-486, the so-called abortion pill, prevented breast cancer tumors in mice with a genetic mutation that made them highly susceptible to the disease, researchers at UC Irvine report today.

The mutation in a gene known as BRCA1 leads to uncontrolled cell growth in the mammary glands. About one in 800 women inherits a version of BRCA1 that is damaged in some way, and the National Cancer Institute estimates that up to 80% of such women will develop breast cancer.

Cancer researcher Eva Lee and colleagues figured that RU-486 could be used to block the hormone progesterone, whose unchecked production is believed to be a primary cause of hereditary breast cancer.

RU-486 binds to receptors that normally link with progesterone. It is used as an abortion pill because progesterone is needed in the uterus to maintain a pregnancy.  more

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It is amazing what you can find out when you actually study a drug!!!  Interesting study.  Unfortunately, it does need more study.

Tags: Domestic Issues, Healthcare, Medical Ethics/Issues by ecthompson md
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From the News & Observer:

Legislators on Monday gave final approval to a measure expanding the state’s seat belt law to include adults riding in the back seat of passenger cars.

The law would kick in Dec. 1. But for the first seven months — until next July — law enforcement officers won’t issue tickets, only warnings. After that, the law straps back-seat passengers who are not wearing a seat belt with $10 penalties.

The Senate approved the bill Monday night on a 30-17 vote. The measure now goes to Gov. Mike Easley for his signature.

The approved bill is weaker than what many senators wanted. The House reduced the penalty — the Senate had wanted $25 plus $50 for court costs — and exempted back-seat passengers in motor homes.

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So, safety isn’t important in North Carolina?  $10 fine.  The fine for jaywalking is more than $10 isn’t it?  Why should motor homes be exempt?  Aren’t passengers wandering around in the back at high risk of death or injury if they are not belted?  This is an excellent example of politics over data.  It is clear that backseat passengers who are belted have a higher survival rate than those who are not.  This data isn’t new.  It is from 1999, NTHSA -

The principal conclusions are: back seat lap belts are 32 percent effective in reducing fatalities and lap/shoulder belts are 44 percent effective in reducing fatalities when compared to unrestrained back seat occupants in passenger cars. In passenger vans and Sport Utility Vehicles, lap belts are 63 percent effective and lap/shoulder belts are 73 percent effective. The change from lap to lap/shoulder belts has significantly enhanced occupant protection, especially in frontal crashes.

One of these days lawmakers will make laws based on what is BEST for us and consistent with available data!!

Tags: Medical Ethics/Issues, State and Local Politics by ecthompson md
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Wearing my trauma surgeon hat, I wrote this op-ed piece which printed in today’s Asheville Citizen-Times

Over the last couple of weeks there’s been a lot of discussion about motorcycles and motorcycle safety here in Asheville and nationwide. As a trauma surgeon, I thought that my input could be useful.

For some numbers, in the year 2005, Mission Hospital admitted 176 motorcycle crash victims. Approximately one-third of these patients required an ICU stay with the range from a couple of hours to 53 days. Just over 60 percent of the patients wore helmets. The overall length of stay for all motorcycle crash victims was twice that of our general trauma population. The median hospital charge was over $17,000. Surprisingly, and this is a testimony to the whole trauma team, out of the 176 patients only four died.

Since mandatory helmet laws have been repealed in many states, this has given trauma surgeons the unique opportunity to study if helmets really make a difference in survival. A recent study in Michigan compared the outcome of patients before the helmet law was repealed to those patients who presented after. The outcome was striking. The number of significant brain injuries dramatically increased and the severity of brain injury also increased. The length of stay in the hospital and in the intensive care unit was longer in those patients without helmets. Significantly more patients who were not wearing helmets required prolonged rehabilitation after their hospitalization. Finally, as expected, the cost of care was significantly more for those patients who did not wear helmets. The conclusion of this study and many others was the helmets protect the brain and save lives.

A 30-year-old female was riding her motorcycle with several of her friends. She was far away from home. She was involved in motorcycle crash. She was found to have a broken pelvis, which required surgery. Her friends stayed around as long as they could but finally had to return home to their own families. This young lady was stranded here in Asheville. She recovered from her surgery and endured her initial postoperative physical therapy, alone until she could be flown home over 1,500 miles away.

A 65-year-old male who rode motorcycles in his “younger” days, was convinced by his grandson, who bought a used motorcycle, to help him fix it up. Once the motorcycle was fixed, he took a ride to make sure everything was in working order. Unfortunately, he was unable to avoid a truck which pulled out in front of him. The resulting crash threw him over 50 feet. He suffered deep abrasions to both arms and legs. He sustained multiple facial fractures and a traumatic head injury. After three days in the intensive care unit his traumatic brain injury continued to worsen in spite of aggressive therapy and multiple surgeries, the patient was declared brain dead.

In the emergency room, the intensive care unit or the trauma care unit, we deal with dramatic stories like these almost on a daily basis. Motorcycles provide almost no protection to the rider. Therefore, even minor motorcycle crashes can cause significant injuries. Deep abrasions resulting from a fall and skidding on concrete are considered a relatively “minor” injury. Patients who have these injuries will attest that they are not minor. As a matter of fact, they cause major pain and disability. They cause multiple trips to the operating room. Some of these abrasions require skin grafting in order for them to heal.

Motorcycles are inherently dangerous. Enthusiasts are extremely vulnerable to bad automobile drivers. Someone can easily pull out of a “hidden” mountain road or stop suddenly. There is very little that even the most extremely conscientious motorcycle rider can do.

Motorcycle riders can decrease the chance of injury or death by doing a few things:

• Take a motorcycle safety course

• Be conscientious and thoughtful while riding

• Wear leathers (this decreases the chance and the severity of abrasions)

• Always wear a full helmet with a face safety shield

• For more information, please check out the following Web sites — The National Highway and Traffic Safety Administration (http://www.nhtsa.dot.gov/people/injury/pedbimot/motorcycle/motosafety.html) and the Motorcycle Safety Foundation (http://www.msf-usa.org/)

Tags: General, Healthcare, Medical Ethics/Issues by ecthompson md
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Jane at Fire Dog Lake has been at the hospital last several days with her mother.  It seems that her mother has been ill.  I hope and pray (yes, progressives do pray) that both Jane and her mother weather the storm.

Get Well Soon

Tags: Medical Ethics/Issues by ecthompson md
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We have switched programs. We are trying to update and modernize. I hope you like it.

Tags: Domestic Issues, General, Medical Ethics/Issues, Mess O'Potamia (Iraq/Iran/Israel/Palestine), Other Political Thoughts, Sports by ecthompson md
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So, I wasn’t going to comment on this but it has been handled so badly by the Bush administration that I really feel that I have to.

Cheney shot a high ranking, rich republican friend over the weekend with a shotgun. The exact circumstances remain unclear. They were out hunting in South Texas. the called an ambulance. Why not a copter? As a trauma surgeon I’ll tell you that in Texas copters are called at the drop of a hat. The patient is taken to a local hospital and not a Level I or II trauma center which is equipped to handle these situations. Why? (wanted to keep this quiet maybe?)

Mr. Whittington, the victim, was too much for the little hospital so the patient was transported to Corpus Christi. A level III trauma center. I don’t know what tests were done in the hospital but what is interesting is what Cheney does. If you had shot someone by accident wouldn’t you be concerned? Wouldn’t you insist on going to the hospital with that patient? If not in the ambulance then following behind in your car? Cheney doesn’t none of these. He stays at the ranch then has dinner. The local police come to interview Cheney but the secret service sends them away. What’s up with that? Cheney too sick? too intoxicated? too full of remorse to speak with the police? Explain to me how this isn’t elitism at its worst!

During the interview 2 days later with Britt Hume, Cheney states that he had only one beer at lunch. Now, this may be true BUT if I had a dime for every trauma patient that told me the one beer story I would be retired now in Hawaii!!

Did Mr. Whittington get the best of medical care? I don’t know enough of the details to comment. I can only say that if you or I had been shot and a helicopter would have been called and we would have been taken to the nearest Level I or II trauma center. That’s all that I know.

Tags: Bush Administration, Medical Ethics/Issues by ecthompson md
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Now, that it has been several months, what do you think should come out of the Terri Schiavo case?

Tags: Medical Ethics/Issues by ecthompson md
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A recent report found that children are no safer in an SUV then they are in any other car. NO Duh!! This has been proven by a number of studies. BUT it should be mentioned that SUV’s are safer today than there were 5 or 10 years ago. Please note that SUV’s have for the most part gotten smaller and more maneuverable.

New research indicates that, as far as children are concerned, SUVs’ benefits of size are offset by their increased risk of rolling over, making them no safer than ordinary passenger cars.  mo

Tags: Medical Ethics/Issues by ecthompson md
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