Myself and social media co-conspirators at Chest Journal recorded a podcast regarding how physicians can be more involved in social media and the future direction of Chest in social media. It can be downloaded here free from iTunes.
Bridging Anti-coagulation is Dead! Long Live Bridging Anti-coagulation!
I am interrupting my current obsession with Top 5 lists to bring you this important announcement: Peri-operative anti-coagulation, (also known as bridging anti-coagulation) is done! Is it time to stick a fork in it?
Right now you’re probably wondering, what the heck I’m talking about, and why you should consider it important. Currently hundreds of thousands of people throughout the country are on the oral blood thinner coumadin (also known as warfarin) to prevent a blood clot. For those who are on it long term, having a procedure can be problematic, as stopping the drug can increase the risk of blood clots, while continuation of the drug increases the risk of bleeding with surgery. Thus many patients undergo a process known as “bridging” wherein the coumadin is stopped several days before the surgery, and a short acting injectable blood thinner is substituted so that the blood thinning effect of coumadin has time to wane before the surgery. This practice has been perpetuated without very clear evidence that it decreases the risk of blood clots or bleeding, and without much certainty about which people on coumadin need to be “bridged”. Recently, researchers sought to shed some light on this question by pooling together data from several smaller studies looking at patients who underwent bridging to determine what the various risks and benefits of bridging might be. The study “Periprocedural Heparin Bridging in Patients Receiving Vitamin K Antagonists” was published in the Journal Circulation and has received much attention, as it should have as it was co-authored by my former mentor (shout out Dr. Kaatz!) but also since it is the first large scale study of its kind. Continue reading “Bridging Anti-coagulation is Dead! Long Live Bridging Anti-coagulation!”
Coming Soon: Get Your Implantable Defibrillator on Craigslist?
Yes, I know I’m supposed to bring you the stunning conclusion to my top ten list of medical advances. But I was so excited to talk about this article I read recently that I’m bringing you this post instead. The top ten medical advances (1-5) will be up in 2 weeks. Unless I decide to bump it again.
We live in a golden age of technology and manufacturing. An age in which we’ve been spoiled by machines, personal devices and electronics have been created to ever increasing standards. Just a few decades ago, you couldn’t buy a Chevy Nova whose bumper didn’t fall off a week after you drove it off the lot. But today’s cars are engineered so well that they easily go hundred thousand miles and beyond. Consumers expectations are now so high, that to ensure that electronics last the expected amount of time, they‘re engineered to last much longer than that. The cell phone(s) in your closet that you forgot about when you renewed your contract probably makes calls just as well as the one you’re using now.
The same goes for medical devices, particularly crucially important medical devices like implantable cardiac defibrillators (ICD). To ensure that they last the expected amount of time and deliver their life sustaining jolts, they have to be built to last. (For the amount of money they charge for them, they had better be). Unfortunately, building something like an implantable cardiac defibrillator to such exacting standards makes them extraordinarily expensive. Think your average Mercedes Benz expensive. And that significantly raises the bar for entry, particularly for the poor both in this country and abroad. In third world countries, access to such devices is limited to the super wealthy, as private insurance plans are limited and government resources are typically directed towards more elemental aspects of health that affect the larger population. In other words, in countries like India, if you’re fortunate enough to have lived long enough to have a cardiac problem which warrants the placement of a defibrillator, you had better be rich enough to afford one. If not, you’re on your own. Continue reading “Coming Soon: Get Your Implantable Defibrillator on Craigslist?”
Doctors Are Being “Gagged” by Gas Drillers
First of all, let’s all agree on two things. First, that energy independence is good for our country. Second that clean drinking water is also good for the country. The development of America’s huge stores of natural gas, have given us a remarkable opportunity to accomplish the former. In particular, the process of “fracking” has made it possible to increasingly tap those huge natural gas stores. Natural gas sits in rock formations, but releasing it is much more complicated than simply drilling a well and pumping it out. In order to tap the gas, it first has to be liberated from its rocky confines, after which it takes the path of least resistance, in this case is up a gas well. The technique of releasing natural gas from rock formations is known of hydraulic fracturing or “fracking”. The process involves drilling down thousands of feet to create a well. Huge quantities of water, often a million gallons or more, are forced into the well. This opens fractures in the rock and allows the natural gas to escape. The water that was pumped into the well is a proprietary mixture that contains various agents which are potentially hazardous to humans. Only a fraction of the fluid is recovered, much of it stays in the well and is dispersed into the depths, (hopefully) never to be seen again.
The process of fracking has huge potential and not only for the drillers. As anyone who has paid close attention to their gas bill has seen, the glut of natural gas has lead a drop in gas prices, and this comes at a time when we could all use a break on fuel prices. The fact that it’s homegrown means that there are no foreign entanglements, it creates domestic jobs and reduces trading deficits. Natural gas even burns cleaner with less CO2 than gasoline. It’s a veritable win-win for the entire country. The tremendous upside of this cheap, cleaner, home-grown energy source has lead to a boom in the industry, with thousands of wells sprouting up across the country, most use the the process of fracking.
But the rush to cure America’s energy woes has been well, rushed. One has only to look at the results of our attempts to harvest corn ethanol as an energy source to see the law of unintended consequences in effect. In a climate where a modicum of caution would be wise, both the government and the industry has proceeded with what can only be thought of as reckless abandon, summarily sweeping aside questions of safety and health concerns. This was typified in 2005 when the federal government passed what is known as the “halliburton loophole” wherein frackers are exempt from significant EPA regulation.
And that’s where we physicians come in. In the rush to create a business friendly environment for drillers, state governments have generally laid out the red carpet. This includes passing laws to protect proprietary information about the content of fluids being pumped into gas wells during the fracking process. In many states, if a physician suspects water contamination, they may request to know the materials, but must sign a confidentiality agreement thus effectively barring them from disclosing this information to others.
Imagine being the physician in Dallas who saw patients who were exposed to fracking fluid, one of whom developed renal failure. Or the dermatologist in Pennsylvania seeing a cluster of people living near a well who presented with non-healing skin lesions after their water was contaminated. In such a situation it would be paramount for a physician to share this information with other physicians, to discuss the case with other consultants, to inform the public about potential threats. The medical community would need to disperse this information both through word of mouth as well as through published literature. Forcing physicians to sign confidentiality agreements would likely limit the transmission of such information. Even if such communication were technically legal, the confusion and fear created by such laws would make many uncertain about whether they could disclose such information.
I do believe that state governments are trying to do the right thing, in facilitating the procurement of what appears to be a cheap, abundant, domestic energy source and increasing their tax base at a time when it is sorely needed. However, it should be pointed out that government is first responsible to the people they serve. The process of fracking is being looked at with increasing scrutiny by the public as cases of contamination by fracking fluid and natural gas come to light in greater numbers. The current approach only fosters an environment of fear and suspicion and heightens the perception that drillers do not take the public welfare into account.
If the scientific community was allowed greater access to information, the causative agents could be identified, and potentially replaced. Such an approach could be beneficial for drillers. There are indeed historical precedents for this type of relationship. The study of lead, and freon and their subsequent removal from gasoline and refrigeration has benefitted society, yet both of those industries continue to flourish today. In addition, drilling companies with poor track records could be weeded out and replaced by companies with better techniques. This process is the American way. It is taking place as we speak in a number of different fields including the medical community, and the drilling community should be no different.
Should we Deny Insulin to Chocoholics?
I’ve always had a tough relationship with cigarettes and the people who love them. As a lung doctor I hate cigarettes, and I hate that patients I see everyday continue to use them. But I also understand that vilifying smokers seems to be in vogue right now. I figure that if someone does something that is not considered socially palatable, and that does them harm, even as they strive to take treatment for it. . . well it must be a pretty powerful addiction.
Recently I was hanging out with a few physician friends, when the topic of conversation came to treating patients who are smokers. Some contemplated whether patients who smoke should even be prescribed inhalers for breathing disorders. Furthermore, we wondered about whether such patients should be followed up for breathing problems unless and until they quit smoking. Continue reading “Should we Deny Insulin to Chocoholics?”
Marriage and Motorcycles.
Being married to a transplant physician tends to give one a different perspective on life, and in particular, risk taking. For example I’m embarrassed to admit I rarely climb ladders anymore unless it is absolutely unavoidable. Between you and me, the last time I had to change a lightbulb in the garage, instead of using a ladder, I stood on the roof of my wife’s S.U.V. (note to self, need to make up story explaining dent on roof of S.U.V.).
But I must admit, I do have a terrible weakness for speed. And while said weakness has been limited to things with four wheels, I’ve always toyed with the notion of someday getting a motorcycle. I never took up motorcycle riding in my younger years, but now as I see older and older people leisurely riding their hogs, and parking their chrome babies in handicapped designated spots, I wonder; could it really be that risky?
The other day, as we were taking a drive on a minimally trafficked two lane road, a couple of kids went flying by us on sportbikes at near triple digit speeds.
My immediate response; “AWESOME! I WANT ONE!”
My wife’s response; “Young . . . healthy. . . perfect candidates for organ harvesting!”
My desire to ride motorcycles has since waned. Continue reading “Marriage and Motorcycles.”
Top 5 Things You Don’t Know About Your Doctor.
1. Your doctors never actually stood up, raised their right hand and took the Hippocratic Oath. If they did, they don’t remember it. The closest thing they’ve taken to a Hippocratic Oath is that time they swore they’re never again staying at that terrible hotel in Athens with lousy views of the Acropolis.
2. Your doctor’s degree of willingness to do something is inversely proportional to how happy they say they are to do it. As in “I’m happy to do that for you” = “I’m very unhappy to do that for you”. And “I’m more than happy to do that for you” = “I’m extremely unhappy to do that for you”
3. Your doctor doesn’t really know whether the respiratory illness you have is viral or bacterial. Chances are that it’s viral and you don’t need an antibiotic. But if you pester enough, you’ll probably get the antibiotic.
4. When you ask for copies of reports to be sent to your other doctors, you should not take their acknowledgment of your request as confirmation that the task will be performed. We may simply be acknowledging that yes, that would be a good idea in theory, or yes we would approve of that kind of bold initiative taking. However, the back and forth motions of our heads may also just be due to migraines brought on by filling out pre-authorizations for nasal sprays.
5. Your doctor lives in deathly, livid, morbid fear that you are going to sue them, put them in prison, infest their home with termites, send their kids to sanitize sweatshop latrines in China, and send them videos of you partying with their significant other on a yacht in the Mediterranean. That is why you are having your 4th stress test in 2 weeks.
Where Medical Reports Go to Die.
It happens thousands of times a day, all across the country. People go to their doctor’s office after some testing has been performed. The physician, unaware that any testing has been ordered by another physician, asks their usual questions. The patient, awaiting an opinion rendered on the recently performed test begins to answer the doctor’s questions with increasing impatience and trepidation, fearing the worst. “Why is he asking so many questions. . . why is he not telling me the results? Did my cholesterol panel show cancer?” And finally the question comes to the fore;
“ Doctor did you get my test results?”
“No, what test did you have”
“But I told them to send it to you!!” Continue reading “Where Medical Reports Go to Die.”
How Academic Press Releases Can Lead to Free Advertising
You may have noticed the rash of medical news spewing from your favorite news outlets with greater frequency. As a medical professional you probably cringe as you envision the calls that are about to flood your office, “Doctor Smith, I heard a report on the news that this drug you prescribed to help me quit smoking is bad for my health!” or, “I want a referral to The Hoffenheimer Institute to get peduncular ray beam therapy for my hypertension, they are reporting great results!” And, like me, you probably curse the media, as the stream of bogusness is regurgitated in high def. My advice? Don’t hate the game, hate the players. 
The world of medical journalism is an ever evolving competitive landscape. A high-stakes competition between various medical centers, medical societies, drug manufacturers, all jockeying for press, prestige, research funding, and patient volumes. The winners are endowed with brand-name recognition and the cash money that goes with it (i.e. grant money and well insured patients). The losers get sloppy seconds. Continue reading “How Academic Press Releases Can Lead to Free Advertising”
Top 5 OTC Meds That Would Require a Presciption if Released Today
Looking at the administrative, legal, and safety hurdles that drug companies have to jump through today, I can’t help but feel (some, just a little) pity for them. I’m sure right now there’s a drug company executive waxing nostalgic over a bygone era where they could do some basic safety research, wine and dine a few physicians in their favorite tax haven, and then get their drug out there for public consumption. But times have changed, and getting FDA approval for medications is alot harder than it used to be. And unless your drug is a quasi-herbal supplemental type of thing made in someone’s back yard, getting the FDA to allow it over the counter is even harder. Here’s my list of the top 5 OTC meds that, if they had been released today, would require a prescription.
1. NSAIDS: (Aspirin, ibuprofen, naproxen, etc. . .) These medications are great for pain and for their blood thinning effect by blocking platelet function. But they are also great at eroding stomach lining leading to ulcers, causing kidney damage, reye’s syndrome, hearing problems, etc. . . Would this be allowed OTC by the FDA today? Heck no!
Continue reading “Top 5 OTC Meds That Would Require a Presciption if Released Today”