A peak you reach

Friends visiting New York City this summer keep asking if it's safe. As in, will they be catching and suffering from novel H1N1 (swine) flu.

I like to think my friends are pretty sharp, discerning folks (after all, they're choosing my company) so I have to attribute these inappropriate questions to a wider problem.

For reference, here's the latest though probably not last NYC DOH guideline on H1N1, which notes about 900 hospitalization and 45 deaths in H1N1+ patients over three months. About three quarters of these patients had at least one risk factor such as existing lung disease.

This deaths and hospitalizations are concerning, naturally, but some perspective is in order: as many as half a million New Yorkers have been infected with H1N1, and this spring in US cities, we actually saw a smaller fraction of deaths due to infectious respiratory illness, compared with 2008. Also, for reference, based on data from a few years ago, I'm guessing that any given three month period, there are between 10,000 to 15,000 deaths in New York City.

So why were ED's swamped in May? Why are my friends still afraid to come to NYC? Dr. David Newman has some thoughts in EPMonthly:

...with constant messages of swine flu lethality on the nightly news, it is little surprise that ED’s in New York City, departments in a chronic state of over-crowding and crisis, were soon bursting at the seams with record volumes. In some institutions daily ED volumes doubled, as EP’s worked through third-world conditions of extreme crowding, questionable hygiene, extended wait times, and swarms of infectious, coughing congregates all within arm’s reach of each other.

The impact is clear: lives were lost. High quality studies have shown repeatedly that when ED’s experience crowding patients in need of rapid, high intensity care are identified later, treated more slowly, and devoted fewer resources. Mortality goes up during crowding in virtually every condition that has been studied, including MI, sepsis, and others. The irony is stark: Once a critical mass is reached, the more that come to be saved, the fewer we can save.

...The overall management of information during the swine flu of 2009, despite some progress in our access to information, was misguided and dangerous. Frantic media outlets drove a nation to fabricated fears, while state-level institutions not only failed to contain or counteract these messages, but also used expensive, fruitless, prescription-only pills, available to most only in their local ED’s, as a means of false comfort. Instead of using honest information to provide safety, comfort and education, the approach created panic, cost money and resources, and took lives.

All of this was preventable and is reversible for the future. There is no reason why the media cannot be recruited into the information dissemination process...

Unfortunately, there is a good reason why: Responsibly framing public health risks is no longer a role that suits traditional media. They've decided it's just not in their interest.

I remarked on this years ago with West Nile virus, which never will never kill as many as, say, food poisoning or swimming pool accidents.

There are many factors driving the public appetite for health risk information -- and that's understandable. I think it's even ok for news organizations to shuffle around reporting to some extent, to satiate those desires.

But what happened in NYC this spring was media malpractice -- night after night, opportunities to put the risks of swine flu in perspective were passed up for breathless reporting. I recall one occasional, a phalanx of reporters were camped outside a hospital I worked at, providing next to no detail about an infant who died it respiratory distress. It turns out this child did not have H1N1, but communicating that was not a priority -- by the next day the lead story was ED's are overcrowded and schools are closing.

EPMonthly ran a nice sidebar from Dr. Jim Augustine, enumerating the ways in which ED docs can engage the media to get the right message out.

But I'm more encouraged by approaches to bypass traditional media and reach patients directly. Yesterday I heard some encouraging news from the CDC: their emergency twitter feed has over 500,000 followers. Millions saw their videos. This is amazing reach, for public health communication.

It wasn't enough to help ED's this spring. But individual hospitals and the CDC is ramping up their use of social media, even as traditional news sources decline in influence. It's really the first good viral news I've heard in a while.

Under my skin, redux

Here's a followup to that recent post about the frustrations involved with patient-reported allergies.

Somehow I missed this before now, but a group from Cincinnati actually started testing patients who reported penicillin allergies... in the ED!

Our results are supportive of the feasibility of conducting penicillin skin testing in the ED and demonstrate the potential influence of conducting skin testing in the ED. The rate of false-positive reports of penicillin allergy in our patient population was high: more than 90% of patients reporting a penicillin allergy did not have a positive skin test result. These findings are consistent with previous reports from other non-ED patient populations...

...The introduction of penicillin skin testing to the ED environment could help decrease the overuse of broad-spectrum antibiotics in the ED...

It took little time to train the ED docs to administer this common skin test used in clinics, and results were available withing 30 minutes. No special background or skills were required to perform this trial -- it's a great example of tackling frustrating problems with straightforward research design.

A small step

When you have a singular achievement of historical magnitude, well, I imagine it's hard to go back to regular life. And it's hard to resist the temptation to cash in on said achievement.

Buzz Aldrin was on TV the other night, giving yet another interview, and I just got done telling my girlfriend that Neil Armstrong never does that sort of thing -- no celebrity biographies, very few interviews, and certainly no endorsements. I figured he realized that the first man to walk on the moon ought to be above that sort of thing.

Turns out I was wrong. Here's a TV spot featuring Neil Armstrong for... Chrysler. (Armstrong's also had a biography released recently, as well.)

Oh well. The next order of business is tracking down this short film that appeared on SNL nine years ago, an imagined vignette of Neil Armstrong's quiet life now in Ohio, walking around town, minding his business but unable to concentrate on much -- because every few seconds his mind seizes on the fact he was first to walk on the moon.

Until that clip surfaces, we'll have to make do with this other imaginative film: the unedited version of Neil Armstrong's moonwalk (NSFW).

Meeting in the aisle

I have a lot of ways to save or share web pages of interest. There's Evernote, ReadItLater, and good old bookmarks. Plus, bookmarklets make Twittering a page easy, and Note in Reader lets you now star, share or 'like' any page.

With so many ways of highlighting good content, it's kind of sad that I rarely go back to look at the material I select, tag, and archive.

But there was a page I kept coming back to, after I saw it online over the weekend. It's a transcript of an interview between an ex-health insurance exec and Bill Moyers.

I've excerpted just a tiny bit and rearranged it a little here, but it's really excellent and deserves a full read (or watching) if you have the time. via Metafilter.

WENDELL POTTER: ... I went home, to visit relatives. And I picked up the local newspaper and I saw that a health care expedition was being held a few miles up the road, in Wise, Virginia. And I was intrigued.

BILL MOYERS: So you drove there?

WENDELL POTTER: I did. I borrowed my dad's car and drove up 50 miles up the road to Wise, Virginia. It was being held at a Wise County Fairground. I took my camera. I took some pictures. It was a very cloudy, misty day, it was raining that day, and I walked through the fairground gates. And I didn't know what to expect. I just assumed that it would be, you know, like a health-- booths set up and people just getting their blood pressure checked and things like that.

But what I saw were doctors who were set up to provide care in animal stalls. Or they'd erected tents, to care for people. I mean, there was no privacy. In some cases-- and I've got some pictures of people being treated on gurneys, on rain-soaked pavement.

And I saw people lined up, standing in line or sitting in these long, long lines, waiting to get care. People drove from South Carolina and Georgia and Kentucky, Tennessee-- all over the region, because they knew that this was being done. A lot of them heard about it from word of mouth.

There could have been people and probably were people that I had grown up with. They could have been people who grew up at the house down the road, in the house down the road from me. And that made it real to me.

BILL MOYERS: What did you think?

WENDELL POTTER: It was absolutely stunning. It was like being hit by lightning. It was almost-- what country am I in? I just it just didn't seem to be a possibility that I was in the United States. It was like a lightning bolt had hit me.

BILL MOYERS: People are going to say, "How can Wendell Potter sit here and say he was just finding out that there were a lot of Americans who didn't have adequate insurance and needed health care? He'd been in the industry for over 15 years."

WENDELL POTTER: And that was my problem. I had been in the industry and I'd risen up in the ranks. And I had a great job. And I had a terrific office in a high-rise building in Philadelphia. I was insulated. I didn't really see what was going on. I saw the data. I knew that 47 million people were uninsured, but I didn't put faces with that number.

Just a few weeks later though, I was back in Philadelphia and I would often fly on a corporate aircraft to go to meetings.

And I just thought that was a great way to travel. It is a great way to travel. You're sitting in a luxurious corporate jet, leather seats, very spacious. And I was served my lunch by a flight attendant who brought my lunch on a gold-rimmed plate. And she handed me gold-plated silverware to eat it with. And then I remembered the people that I had seen in Wise County. Undoubtedly, they had no idea that this went on, at the corporate levels of health insurance companies.


WENDELL POTTER: ...there's a measure of profitability that investors look to, and it's called a medical loss ratio. And it's unique to the health insurance industry. And by medical loss ratio, I mean that it's a measure that tells investors or anyone else how much of a premium dollar is used by the insurance company to actually pay medical claims. And that has been shrinking, over the years, since the industry's been dominated by, or become dominated by for-profit insurance companies. Back in the early '90s, or back during the time that the Clinton plan was being debated, 95 cents out of every dollar was sent, you know, on average was used by the insurance companies to pay claims. Last year, it was down to just slightly above 80 percent.

So, investors want that to keep shrinking. And if they see that an insurance company has not done what they think meets their expectations with the medical loss ratio, they'll punish them. Investors will start leaving in droves.

I've seen a company stock price fall 20 percent in a single day, when it did not meet Wall Street's expectations with this medical loss ratio.

For example, if one company's medical loss ratio was 77.9 percent, for example, in one quarter, and the next quarter, it was 78.2 percent. It seems like a small movement. But investors will think that's ridiculous. And it's horrible.

BILL MOYERS: That they're spending more money for medical claims.


BILL MOYERS: And less money on profits?

WENDELL POTTER: Exactly. And they think that this company has not done a good job of managing medical expenses. It has not denied enough claims. It has not kicked enough people off the rolls. And that's what-- that is what happens, what these companies do, to make sure that they satisfy Wall Street's expectations with the medical loss ratio.


WENDELL POTTER: Right. Right. And they're Democrats. And my executives wanted to meet with — and when I say my, the people I used to work for--


WENDELL POTTER: Yeah, wanted to meet with Hillary Clinton, when she was still in the Senate and still a candidate for president. Well, that's hard to do. That's hard to pull off, but she did. That just shows you that you can, through the relationships that are formed and that the insurance industry pays for, by hiring these lobbyists, you can your foot in the door. You can get your messages across to these people, in ways that the average American couldn't possibly.

BILL MOYERS: So it's money that can buy access to have their arguments heard, right?

WENDELL POTTER: That's right.

BILL MOYERS: When ordinary citizens cannot be heard.

WENDELL POTTER: Absolutely right. It's the way the American system has evolved, the political system. But it does offend me, that the vested special interests, who are so profitable and so powerful, are able to influence public policy in the way that they have, and the way that they've done over the years. And the insurance industry has been one of the most successful, in beating back any kinds of legislation that would hinder or affect the profitability of the companies.

BILL MOYERS: Why is public insurance, a public option, so fiercely opposed by the industry?

WENDELL POTTER: The industry doesn't want to have any competitor. In fact, over the course of the last few years, has been shrinking the number of competitors through a lot of acquisitions and mergers. So first of all, they don't want any more competition period. They certainly don't want it from a government plan that might be operating more efficiently than they are, that they operate. The Medicare program that we have here is a government-run program that has administrative expenses that are like three percent or so.

BILL MOYERS: Compared to the industry's--

WENDELL POTTER: They spend about 20 cents of every premium dollar on overhead, which is administrative expense or profit...

So, yeah. I don't usually share or post much on healthcare reform. There's a lot of stakeholders in US healthcare, they make a lot of good points, and it's difficult for me to reconcile the proposals and theory with the forces at work in the emergency department. Plus, the risk of alienating some prospective employer with my forever-googlable opinions always seemed to outweigh the benefit of trying to persuade some anonymous readers.

But I was interested in what Wendell Potter had to say. I know, he's got a new job and a blog and therefore, undoubtedly, an agenda of his own. Maybe it's just his skill in PR but he seemed like an honest guy, and that's something I've been looking for in this debate for a long time.

Today, some other bloggers head to DC to discuss healthcare reform -- Dr. Val, Dr. Rob, Dr. Wes, Kevin MD, Emergiblog, Kerri and others.

I've read these people's words for years. Interviewed them all for Medscape. Some, I've met in person. One, I almost met, but my hospital caught fire, and then I recovered his iPod and earned a llama.

Yes, many of them have forged ties to industry and agencies. And many of them are advancing an agenda of their own, or at the very least, a podcast. But unlike the Potters and Moores and Becks of the world, well, I know these folks, and they seem like honest and good people. Even the guy giving out the llamas. So I recommend you all listen to them, and bookmark Better Health, and retweet, and Note in Reader, and save to Evernote, and whatever else you do with thoughtful material.

Update: The #patientsfirst hash will get you the twitterfeed of the event. A helpful blogger has generated this pdf transcript of the conversation.

To leave me here on shaky ground

So, five years ago, I wondered if the delays in approving, and obstacles in administering, drugs like clozapine (Clozaril) could actually be used to hold parties liable for deaths that occurred while deserving patients weren't getting their meds.

This was kind of a thought exercise, as I understand it would be extremely difficult to measure. But I thought the notion of holding administrators, bureaucrats and lawyers as accountable for their decisions as physicians was one worth exploring.

So I was intrigued to reports of a new study in the Lancet that started like this:

"Thousands of people with schizophrenia worldwide could have been saved if doctors had prescribed them the anti-psychotic drug clozapine, a new study says."


This was the largest study yet to look look at mortality and antipsychotic use. The authors' aim was to examine the mortality gap between the general population and those with schizophrenia, on or off meds. The accompanying editorial phrased the study's findings succinctly:

"Tiihonen and co-workers address a crucial question—to what extent do second-generation antipsychotic drugs contribute to excess mortality in people with schizophrenia? This question has loomed large since reports of raised risk of weight gain and diabetes associated with some of these drugs. Even the earliest studies of weight gain and incident diabetes suggested substantial heterogeneity across second-generation antipsychotics for adverse metabolic effects. Subsequently, large clinical trials, including the CATIE study, have confirmed that different drugs have different metabolic liabilities. Now, differences in mortality also seem to exist between drugs. In today's study, current use of quetiapine was associated with the highest risk of death, with a hazard ratio of 1·41 (95% CI 1·09–1·82) compared with current use of perphenazine. Current use of risperidone was also associated with a (34%) increased risk of death, compared with current use of perphenazine.

Analyses of cumulative use of antipsychotics did not show an increase in cardiovascular mortality in patients taking olanzapine and clozapine over the 11-year study. This finding is surprising in view of the substantial evidence of heightened cardiovascular risk associated with these two drugs. Clozapine was, in fact, associated with a much lower risk of death than was any other antipsychotic treatment, and a substantially lower risk of suicide than with any other medication. Even though people with clinically significant medical comorbidities might be excluded from clozapine treatment and the eventual burden of cardiovascular mortality could take decades to emerge fully, this finding is still striking. Furthermore, these results mean that the reports of under-use of clozapine in African–American patients with schizophrenia are of even greater concern."

The authors make a suggestion:

"...our results raise the issue of whether clozapine should be used as a first-line treatment, because it seems to be the safest antipsychotic in terms of mortality and it is also the most effective.

However, clozapine is inexpensive, and hence it is unprofitable for the pharmaceutical industry to market compared with other second-generation antipsychotic drugs. Additionally, monitoring schedules are a drawback that would be encountered with heightened use of clozapine,and physicians and other hospital staff might therefore be reluctant to initiate clozapine treatment. However, clozapine is associated with a lower discontinuation rates than is any other antipsychotic, and monitoring is not likely to be a major difficulty for patients after the initiation of treatment."

So, after all these years, even with the much-emphasized risk of agranulocytosis and weight gain, clozapine is the safest atypical antipsychotic? At least, in Finland? I'm no psychiatrist, and the only time I order atypicals are when I'm caring for boarded patients already taking these drugs. The docs over at Furious Seasons seem appropriately skeptical.

Still, it's interesting that the media is making this leap, and framing the study in terms of 'lives that could have been saved' -- a step the authors and editorialists weren't willing to take, and one that I don't recall seeing during the news from, say, the WHI hormone replacement reversal. It's an interesting way to frame results because, unlike 'number needed to treat' or 'likelihood ratios,' 'lives that could have been saved' implies liability -- not just for doctors but for bureaucrats and drug marketers. It's a metric that lends itself well to ... thought exercises.

Via @PharmaGuy (forum post)

Under my skin

There's a satisfying post on WhiteCoat where he rants against patient-reported allergies. A sample:

When I ask patients about their medical allergies, more often than not patients suffer from at least one. During a recent shift, I had 17 people who told me that they had medication allergies. When someone has an allergy, I always ask what the allergic reaction is. The responses I received included the following:

* Seven people had allergies to various medications (most often penicillin) because their parents told them they had a reaction as a child. They didn’t know what the reaction was, but they have never taken the medication since.

* Four people had nausea and vomiting with medications that typically cause nausea and vomiting as one of their side effects...

He's right -- a lot of people have unwarranted concerns about mild or entirely predictable reactions, and sometimes this can be frustrating on a busy shift. But I also like the commenter who wrote:

I’m not sure how you think the patient is supposed to know which things actually require medical attention, especially when doctors and nurses refuse to give any guidelines over the phone. 'Come on in, and if you aren’t seriously ill, then we can make fun of you on the blog tomorrow.'

Patient perceptions of allergies is a subset of a larger issue facing all of emergency medicine -- patient perception of disease. We don't expect patients to triage themselves, or figure out which symptoms are worrisome and which are benign. That's our job. I try to look at proper allergy reporting as another opportunity for patient education (my favorite is explaining why someone can't be allergic to the iodine atom).

More importantly, from the informatics perspective, allergy reporting is a big frustration as well (and one we can actually do something about, ourselves). Patient-reported allergies find their way into every EMR, and trigger the most inane alerts and stops, forever. If a patient reported vomiting once after codeine, every subsequent doctor who sees this patient will have to jump through electronic alert hoops just to order IV morphine. It doesn't matter if the patient is taking oxycontin and wears three fentanyl patches. The same goes for antibiotics -- I think most lay folks would be surprised that we have to wrestle, years later, with the inherited family warning of about penicillin reactions, even when ordering a 4th-generation cephalosporin with essentially no cross-reactivity...

There's no intelligence built into the system, yet, I think because everyone's afraid that if a patient has a bad outcome because that 14th medication alert was eliminated, they'd be liable. This line of thinking ignores the notion that bad outcomes are probably happening because there are so many useless alerts, they all tend to be ignored.

Someone told me recently (perhaps it was Dr. Reider?) that non-clinical folks involved in setting up electronic health information exchanges thought that communicated allergies to new providers would be the top priority, and were surprised when physicians considered allergies to be less important than, say, recent EKG's, imaging, current med lists, and the like.

I wonder if this attitude toward allergy records is because we don't think most allergies are that serious, because we can most often treat whatever arises... or because we're overcome with alert fatigue.

Whatever the reason, there's no doubt in my mind that if we had an intelligent, efficient system to process patient-generated allergy reports, we'd be less frustrated with this information, and more sympathetic to the patient's concerns.

Movin' on up

Congratulations to Drs. Graham Walker and Liam Yore, who've made the leap from home-grown bloggers to big-time, institutional blogging over at ACEP's The Central Line.

Also, an excellent development in the other direction: Longtime columnist for ACEP News, Dr. Michelle Lin, now has her own blog: Academic Life in Emergency Medicine. She's providing DVD-like bonus material behind each new Tricks of the Trade column, and also describing her experiences balancing teaching, research and clinical responsibilities.

And bonus: The Examining Room of Dr. Charles is back open for business!

Sleep to Dream

I enjoyed NYC Dr. Kent Sepkowitz's column in Slate the other day -- Paging Dr. Feelgood -- where he recaps the careers of some celebrity docs and tries to imagine the pathway to enabling addicts. Key part:

In a strange way, I actually stand in awe of these guys. I have taken care of a few celebs in my career, and for me it was an awful experience. If you fuck it up, you're toast. Once I took care of a very important person, a person you have heard of and are very interested in, someone you would be shocked to know had the problem—asthma—that I treated him for. Well, almost treated him for. His complaints and his recollection of near death last time he had the identical symptoms so unnerved me that I asked a colleague to assume his care.

But the Dr. Feelgood experiences no such hesitancy... Perhaps it all starts innocently—a rich, famous guy with a tiny problem walks into the office. He can't sleep at night. He's so friendly, sincere, not stuck up like some celebs. Then he comes back a week later because of a sore ankle, wanting a little codeine and bearing an autographed photo or a CD. Other patients notice and figure you must be a pretty good doctor if Mr. Showbiz is coming in....

I once wrote about that concern over VIP complaints, in a medscape column. And, like the author, the only thing that impresses me about these celebrity docs is their creativity -- Sepkowitz describes how the first Dr. Feelgood used solubilized placenta. And, while the risks of propofol dosing are drummed into our heads in training, it never occurred to me a doctor-to-the-stars might use propofol outside the hospital on an unmonitored patient.

While it didn't surprise me that propofol has been considered in
palliative care
and even implicated in a murder, it turns out propofol (diprivan) abuse and dependency is not unheard of and, as this review by Roussin shows, some IRB actually permitted trials:

Normal healthy volunteers (n = 12) were exposed in a blind fashion to acute bolus injections of 0.6 mg/kg of propofol and to a similar volume of soy-based lipid emulsion (similar to the vehicule of propofol) twice. After these sampling sessions, they were asked to choose which drug they preferred to be injected with. Propofol was chosen by 50% of the subjects, and seemed to have been based on the pleasant subjective effects. In contrast, the choice of placebo (Intralipid®) seemed to have been based on either non-intense subjective effects during the propofol sampling session (increased dizziness, confusion) or residual effects (fatigue) after the sessions. These results suggest that, in some healthy volunteers, propofol functioned as a reward.

...From a psychopharmacologists' standpoint, propofol shares properties in common with many drugs that are abused. In particular, the onset of the effects of propofol are rapid and this drug makes people 'feel good' and feel relaxed [45]. The mood-altering effects of subanaesthetic doses of propofol delivered via an infusion or by an acute bolus injection have been assessed in human healthy volunteers [44,52]. Subjects reported feeling high, lightheaded, spaced out and sedated....

I read up on propofol use a lot a year ago, in preparation for a talk on procedural sedation. At that point I think its only foray into pop culture's collective consciousness was a poem by Karl Kirchwey called "Propofol" that ran a year ago in the New Yorker. It began:

Moly, mandragora, milk of oblivion:
I said to Doctor Day, "You bring on night."
"But then," he said, "I bring day back again,"
and smiled; except his smile was thin and slight.

Now everyone's talking about propofol. The ASA is using this opportunity to reintroduce talk of restricting propofol to their specialty alone (despite abundant and mounting evidence that it's used safely in ED procedural sedation). Reporters are wondering why propofol administration is not as closely logged as, say, opiates.

All this activity suggests it soon will be. And while keeping this drug out of the hands of abusers and enablers is a worthy goal of regulation, I hope those who've demonstrated a safe track record are not prohibited from using this unique medication.