Telemedicine and Acute Stroke Treatment

My community hospital is holding its quarterly physician staff meeting and one of the items on the agenda will be a bylaw change which will permit outside physicians, not credentialed or vetted by our hospital credentials committee, to perform video consults on patients within our hospital. Hospital administration is pushing this bylaw change, and since there has been a quiet coup which has transferred medical staff power from the community’s practicing physicians to the hospital employed and paid physicians, it is a foregone conclusion that it will easily pass.

The bylaw change is being requested because the hospital would like to continue to reap the benefits of being an ischemic stroke comprehensive treatment center and offering the health benefits to the community despite not being able to meet the criteria. If a patient presents to the emergency department within four hours of developing ischemic stroke symptoms they must be offered the administration of a “clot busting “drug Alteplase (t-pa). The patient must not have any bleeding tendencies and no evidence of active bleeding or a mass or tumor on head CT scan and must be examined by a neurologist within 45 minutes of arrival.

The problem is that most community based neurologists with outpatient office practices and hospital staff privileges cannot and will not drop everything they are doing and run to the emergency department to evaluate a new patient each time a stroke protocol patient arrives. When given an ultimatum by the hospital administration, that they must take call and be available within 45 minutes, our community neurologists en masse relinquished their hospital privileges.

The hospital countered by bringing in several research oriented academic neurologists and neurosurgeons to man the beautiful new Neuroscience Institute and provide coverage of the ED for the stroke protocol. Few if any of these physicians were able to develop and maintain a practice within the community and they have since left. The Emergency Department is staffed by employed board certified emergency physicians who are well qualified to diagnose an ischemic stroke and administer t-pa. They refuse to do so citing the liability of a poor outcome as the reason. Despite data indicating the benefits of t-pa administration in these situations, the 6 out of 100 chances of a bleed in the brain plus the 1 in 6 chance of death is enough to deter their participation.

You would think that since the hospital hires these physicians the logical choice would be to fire them and hire a group that will provide the state of the art care in a timely fashion. This has not occurred. You would think that the state legislature would grant the ED physicians sovereign immunity from medical malpractice suits if the patient meets the criteria for the ischemic stroke protocol and the patient is given appropriate informed consent for the procedure but this common sense legislation has not been developed or passed.

The hospital has chosen a different pathway. They are opting to hire neurologists from a university medical center who will provide video consults on ischemic stroke patients from an offsite location. Robots will actually examine the patient and televise the data back to the telemedicine center after an emergency department physician performs a brief initial evaluation. The neurologist off site will then provide the needed neurology consult to proceed with the injection of the clot buster.

I suspect the mechanism will work like this. A patient or family member will call EMS via 911 and be taken to the Emergency Department. A triage nurse will ask all the questions to qualify the patient for the t-pa protocol; a robot will examine the patient and transmit via TV the data to an offsite neurologist while an ER physician does an exam. A CT scan of the head and brain will be performed. If no bleed is discovered or tumor or mass that could bleed, t-pa will be administered by the pharmacy and nursing staff. Further intervention by an interventional radiologist and or neurosurgeon may then occur.

At no point in this protocol does it call for the patient’s primary care doctor or cardiologist or usual neurologist to be called. We will be called once the procedure is complete because neither the ER physician or the neurosurgeon or the interventional radiologist will want to admit the patient to neurology ICU. While our surgical ICU and Medical ICU/CCU are covered 24 hours per day by an outsourced hired intensivist group, the neuro ICU does not have that type of coverage.

I can hear it now, my phone ringing and upon picking it up I hear the voice of a clerk in the Emergency Department, “Hello Dr Reznick, Dr. Whateverhisorhername wishes to speak to you about patient Just Had A Stroke.” I get put on hold for five minutes and then in a flat nasal voice, “Hello Steve your patient came in earlier by EMS with symptoms of an acute ischemic stroke. They met the t-pa ischemic stroke criteria and were treated. Unfortunately, they had a major hemispheric bleed with mass effect and edema and are now unresponsive and intubated on a ventilator. We need you to come in and admit him and care for him.”

I will vote in protest against this bylaw. I will lobby for recruiting neurologists who are hospital based who will actually see the patient and care for them. I will lobby for a new state law to provide sovereign immunity for ED physicians treating ischemic strokes according to the internationally recognized protocol. I will lobby for our medical and surgical residents on site and in the hospital to be permitted to administer t-pa after meeting the appropriate criteria. I will not support out of the area physicians making the final call and leaving our local physicians to deal with their results.

My First Day on the Job …

There has been a great deal of discussion about doctors’ in training work hours and work load. In June of 1976 I reported to the Jackson Memorial Hospital complex three days in advance of my start date for orientation. I was given a tour of the facility, filled out countless forms and waivers, received my ID badge and was ultimately sent to the Department of Medicine to receive my assignment.

Sitting in the conference room and looking at the patient assignment and ward team assignment list I found myself at the bottom of the list. “Elective Rotation – Steven Reznick MD Neurology.” While all my colleagues in the internal medicine training program left to meet their new residents and meet and learn their patients I was sent to the neurology department in the next building to perform neurology consultations. When I got to the Neurology Office the Chief Resident laughed at me. “Reznick you are on elective. There is no night call. You start in three days. Go home and enjoy your last three days of freedom. Be here at this office at 9 a.m. and we will see what if any consults we have to do.”

Three days later at 7 a.m., filled with anxiety, I arrived at the neurology office which was locked and closed. At 8 a.m. a secretary arrived, showed me where to sit and I waited. At 8:50 a.m. no one had arrived yet on the medical staff and she received a phone call. “Dr. Reznick that call was from your chief resident in Internal Medicine. He needs to see you now in his office.” I asked directions on how to get there and off I went.

The Chief Resident had just completed his three years in internal medicine and was now entering an administrative and research year. He greeted me with, “Reznick I am not sure how you managed to be so unlucky but I have to reassign you from elective to Ward Team III on South Wing 8. You have eighteen patients on your service and you do not have the luxury of three days to learn them. By the way, here is the team pager and you are on call today and tonight.” “How did I get so lucky? “ I asked. “We originally had an anesthesia resident rotating through medicine but he decided after orientation that he did not want to be a doctor so he just left.”

The Chief gave me directions to SW-8, which was at least air conditioned, and off I trudged. Upon arrival I went to the nursing station, introduced myself to the charge nurse and asked if my ward team was around. “They are not back from morning report yet but we need you in 828. The priest arrived fifteen minutes ago and they are waiting for you to terminate life supports.”

My first patient was 28 years old with widespread metastatic terminal breast cancer. After multiple seizures from brain metastases and an unsuccessful CPR attempt she was “brain dead” on a ventilator. Her family had chosen to terminate life supports and my role was to walk in, disconnect the ventilator and pronounce her dead when she stopped breathing. I walked in, introduced myself, shook hands all around and listened to the family talk about my new patient. When it was time the nurse and priest walked to the ventilator and disconnected it with me holding my hands so I did not feel like I was doing this alone. The nurse adjusted the morphine drip and the patient peacefully and calmly ceased breathing. I listened for a heartbeat, felt no pulse, saw no respirations and spoke to each family member and the priest as my pager screeched, “Call 4125 MICU for a transfer.” I found a phone and called. AC, an intern said, “Hi Steve. We are transferring a 23 year old with rhabdomyolysis and acute tubular necrosis (kidney failure) just off peritoneal dialysis with calcium of 16 out to the floor because we need a bed for a younger more salvageable patient. Can you come get him please?”

The charge nurse on SW-8 gave me directions to the MICU and it took me five minutes to walk there. Out in the hallway was a large stretcher with an even larger gentleman on it with two IV lines running almost wide open and three volumes of charts each larger than the Encyclopedia Britannica. There were no transporters or orderlies to move the patients at this large public hospital so I was left to push the bed along the course I had just walked to get back to SW-8. We walked through non air conditioned East Wing which was considerably more difficult pushing a stretcher than on the original trip.

On the way I introduced myself to Frank, my new patient and began to take a history. Poor Frank was a furniture mover who developed a fever and chills while moving a piano up some stairs and, when he got home and went to bed, had terrible muscle pain. He was too weak to get up so he called 911 and was brought to the hospital three months earlier. For some reason his muscles had decomposed due to the infection, heat and bad luck. The dissolving muscle enzymes were like molasses as they passed through the filtration of the kidneys clogging them up and sending him into acute and life threatening kidney failure. He had survived dialysis and infection and was now being bumped out of the unit for a “younger more salvageable patient.”

When I got back to SW-8 and placed him on his bed I sat down with his chart, overwhelmed and considered using the same option that the anesthesia resident had exercised. I was reading and crying when I felt a hand on my shoulder, looked up and my new resident introduced himself. “You have had a tough morning. Let’s go to the blackboard and talk about hypercalcemia and how to treat it. I bet you know far more than you think you do. I have you covered, don’t worry.”

We were almost through his chalk talk and were about to examine the patient when the beeper screeched again. “Please call 4225, the ER. We have a GI bleeder and he is your admission if he doesn’t arrest before you get here.” John, my resident, jumped up and screamed, “Follow me.” He was running full speed, down the stairs and towards the ER. It was a ½ mile run if not more. When we arrived, sweaty and panting for breath we noticed a jaundiced man surrounded by doctors and nurses with blood spurting upwards from his mouth like an oil well that had just been opened wide. John pushed them aside, felt for a pulse and said to me, “Start CPR.” I got up on the stretcher and started compressions with each compression producing a geyser of blood out of his mouth and on to my white coat and clothes. There were no goggles. There was no barrier protection. “Stop compressions, “he ordered. “There is no pulse or blood pressure, let’s call it.” “Time of death 9:55 a.m.” John directed me to the chart where I wrote a brief note, called the next of kin and informed them and then changed into clean scrubs. “We have about an hour or two now before another admission so let’s go back to the floor, finish up with your surviving patient and get to learn the others.”

At 7 p.m., having rounded with me on all my new patients, John asked me if I had eaten all day and did I live alone. I told him I had not eaten anything since coffee in the neurology office and I was married. He suggested I call home and tell my wife that I wasn’t coming home that night. “Let’s get you to the cafeteria, get you some nourishment and let me introduce you to the resident covering you and Dr Homer tonight.” Since I was not assigned to patient care at orientation, I had not been issued meal tickets. I had about five dollars in my wallet so John gave me some of his meal tickets for a meal. John was a saint. My covering resident was his equal. “Pat” called me a “thoroughbred stallion who needed to be brought along slowly.” She gave me her pager number and told me to call her if I got an admission or if I had a patient care issue. The two other interns on our team were excellent. They made me a summary of their patients and wandered home at about 8 p.m.

The time from 8 p.m. until 3 a.m. was a vast blur. There was an admission of an elderly gentleman with pneumonia. It required drawing all his bloods, labeling the tubes and carrying them to the lab. I had to wheel him to x-ray for a chest x-ray (there were no CT Scans yet), obtain a sputum specimen and gram stain it for Tuberculosis. There were the three blood cultures to draw, starting the IV line and antibiotics and of course writing the admission note and orders and dictating them. There were countless calls from nurses about infiltrated IV lines to be restarted, headaches, fevers requiring me to show up and draw blood cultures, family members calling to discuss their loved ones status.

At 2:30 a.m. I wandered into the ER because I was up for the next admission. “Pat” looked at me and said, “Go into the lounge, lie down and take a nap. Give me your pager. If anything comes up I will wake you. You need a nap.” That simple act of kindness and consideration and a 30 minute nap was like a shot of Café Cubano and adrenaline and, when 7 a.m. work rounds began with my ward team back on site with my resident John, I was relatively fresh to face a new day. I passed the pager to Phil, the other intern, as he asked me, “How did it go?” Somehow I mustered up a “No sweat especially with resident coverage from John and Pat.  John is covering you tonight so I expect you will be fine!”

We got very little sleep during my internship (PGY1) and residency training. We worked 100 plus hours weekly. The patients we saw were mostly severely ill and complex. We did all the lab work ourselves in the ER house staff lab. We started all the IV’s, drew all the bloods, and transported the patients ourselves. The work was physical, demanding, cerebral, emotional and exhausting. Every new patient was seen by an ER physician and attending, an intern, a medical student, a covering resident.

They were reassessed at 7 a.m. on work rounds with your resident and ward team plus often the chief resident. At 9 a.m. you presented the new admissions to a faculty member and the entire residency class at morning report. At 10 a.m. you presented the case to your team attending physician on attending physician rounds. This faculty member reviewed the case, examined the patients and wrote a note documenting agreement with the care plan. At noon your resident presented the case to the Chief of Staff at Chief of Staff Rounds. By 1:00 p.m. the problems and decision making had been reviewed and discussed by six or seven physicians. Sleep was not an issue in decision making because we had so many immediate layers of patient decision making reviews.

Our overworked supervising residents for the most part were caring and helped us out if we were exhausted or in over our heads. Our chief residents were available around the clock if we needed extra help.

I do not want today’s doctors to have to work as hard and perform the menial tasks that I was required to do for any reason let alone because I went through it and survived. I do not believe that the layers of supervision and questioning of your decisions allows for sleep deprived errors and mistakes if everyone is doing their job appropriately. I do feel fortunate that I learned to stain specimens and look at them under the microscope and run electrolytes on flame photometers and learn how to set up cultures of blood and urine on culture plates then read them. It taught me the time involved and the limitations of the test plus the margins for error.

I do believe the high volume of severely ill individuals I cared for broke me down and made me a dehumanized efficient machine. I was fortunate that caring faculty built me up and reminded me why I went into this profession to begin with.

Last week a prospective new patient came by to meet me at my office and see if he wanted to join my practice. During the discussion he lifted his shirt and showed me some scars on his abdomen. “You don’t remember me? You gave me those scars inserting catheters to do peritoneal dialysis on me on SW-8 on your first month as a doctor. I remember how frightened you were that you would hurt me or kill me. I was suffering from kidney failure and high calcium after my muscles broke down from an infection. You treated me for six weeks after I left the ICU and transferred me to an acute rehabilitation hospital where I learned to walk again. I live in this area now and I found you on line and want to be your patient again.”

It’s incredible how life always seems to come around full circle!

Flu Activity at Its Local Height. Flu Shot Effectiveness Set at 48%.

The most recent epidemiologic data from the Center for Disease Control states that this year’s flu shots reduced a patients chance of catching the flu by 48% compared to no vaccine at all. The party line is that those individuals who were vaccinated and still contract Influenza A or B get a milder version. In this week’s Morbidity and Mortality Weekly Report, Brandon Flannery, PhD, of the CDC and associates believe the flu vaccine is about 43% effective against influenza A and 73% versus Influenza B. Most flu infections this season have been caused by Influenza A (H3N2). This particular virus has the ability to change its genetic composition frequently thus making updates to vaccines necessary more frequently than current manufacturing methods can accommodate.

We are heading into the peak weeks of Influenza A infection in Palm Beach County, Florida. Individuals with flu and upper respiratory tract infection type symptoms should see their doctor. An Influenza Nasal swab test can determine if you have the flu. It takes about fifteen minutes to learn the test result after obtaining a nasal swab. If you have the flu we can place you on a dose of Tamiflu to cut the duration and symptom spectrum of the infection. We can also recommend a ten day course for family members and intimate partners as an effective prevention against the disease. Call the office if you have any questions.

Zika Update

Zika is an infectious virus introduced to Florida by individuals who traveled to South and Central America plus the Caribbean Islands and were infected by the bite of an aegypti mosquito or a close relative of that mosquito. They then brought the infection back to the USA. The disease has an incubation period of less than two weeks and generally produces a mild illness that most adults do not even know they have. Fever, aches and pains, a fleeting rash, headache and conjunctivitis are common symptoms. Once infected the disease can be transmitted from human to human by body fluids during sexual activity. It can additionally be transmitted when an infected individual is bitten by a mosquito and then it bites a human being. Fortunately the mosquitoes have a flight range of about 100 yards. It is the mobility of infected human beings causing the geographical spread of the virus more than mosquitoes. The virus infects a male’s semen and can remain infectious for about six months. This has led to the suggestion that infected men use condoms when having sex for six months post infection.

The disease is mild in adults but the body’s response to infection has produced a neurological ascending paralysis known as Guillan Barre Syndrome (GBS) at three times the expected rate of this diseases occurrence.  GBS is painful and can affect our respiratory muscles necessitating the use of mechanical respirators and ICU care for survival. The disease is most dangerous in pregnant women causing permanent brain and developmental damage and death in developing fetuses.

At the current time treatment is supportive. There are lab tests to detect an infection using blood and urine specimens. A vaccine to prevent infection is under development with early success noted in rhesus monkeys. Prevention at this point involves practicing safe sex, avoiding mosquito bites using repellant and appropriate clothing.  The mosquito spreading Zika bites during daylight hours. Spraying to reduce the mosquito population is an ongoing strategy being hampered by poor funding. An experimental project to introduce sterile genetically engineered female mosquitoes is being hampered by lack of funding and citizen concern about potential dangers of releasing mutated mosquitoes.

President Obama asked Congress last spring for 1.9 billion dollars to fight Zika but Congress adjourned without providing any funds. The CDC used other funds to begin the research and fight against Zika but is rapidly running out of funds.

Glucosamine and Chondroitin Sulfate Preserves Knee Cartilage in Osteoarthritis

My brother in law is a well-respected researcher and biochemist. Thirty years ago he treated his post exercise aching knees with glucosamine and chondroitin sulfate and felt better. Since then he is a fan. Although he is a firm believer in the scientific method and double blind controlled research studies, we could not find any research to support his observations.   The discussion then turned to, “it helps me and it doesn’t hurt me so why not?”

In a double blind study sponsored by the National Institute of Health known as GAIT, 1500 or more patients with osteoarthritis and a painful knee were randomized to either receive glucosamine and chondroitin sulfate, each substance individually, Celebrex or placebo for six months. The results showed neither led to reduced pain.

Several other studies were as non-conclusive. In the few studies where pain was reduced the study methods and design were criticized and the results were felt to be questionable as were the conclusions of the researchers.   There was nothing positive to say about glucosamine and chondroitin sulfate until a recent study by Martel- Pellitier, Canadian researchers published in Arthritis Care and Research those individuals who took the combination for six years or greater tended to preserve their knee cartilage better than those who did not.  While the knee cartilage was maintained there was no difference in pain or complaints of symptoms between the treated and non- treated group. They believe that by preserving knee cartilage over time there may be less necessity for that joint to be replaced eventually.

I am sure over time this will be studied as well. In the meantime glucosamine and chondroitin sulfate seems to have little toxicity and ultimately my brother in law may be on to something positive.

How Tightly Should We Control Blood Pressure in the Elderly?

A recent publication in a fine peer reviewed medical journal of the SPRINT study proved that lowering our blood pressure to the old target of 120/80 or less led to fewer heart attacks, strokes and kidney failure.  There was no question on what to do with younger people but to lower their blood pressure more aggressively to these levels. Debates arose in the medical community about the ability to lower it that much and would we be able to add enough medication and convince the patients to take it religiously or not to meet these stringent recommendations?

There was less clarity in the baby boomer elderly growing population of men and women who were healthy and over 75 years of age. The thought was that maybe we need to keep their blood pressure a bit higher because we need to continue to perfuse the brain cells of these aging patients.

A study performed in the west coast of the United States using actual brain autopsy material hinted that with aggressive lowering of the blood pressure, patients were exhibiting signs and symptoms of dementia but their ultimate brain biopsies did not support that clinical diagnosis. In fact the brain autopsies suggested that we were not getting enough oxygen and nutrient rich blood to the brain because of aggressive lowering of blood pressure.  Maintain blood pressure higher we were told using a systolic BP of 150 or lower as a target.

A recent study of blood pressure control in the elderly noted that when medications for hypertension were introduced or increased a significant percentage of treated patients experienced a fall within 15 days of the adjustment in blood pressure treatment.  This all served as an introduction to a national meeting on hypertension last week during which the results of this same SPRINT (Systolic Blood Pressure Intervention Trial) strongly came out in favor of intensive lowering of blood pressure to 120/70 to reduce heart attacks, strokes and mortality in the elderly and claimed even in the intensive treated group there were few increased risks.   On further questioning however by reclassifying  adverse events in the SPRINT trial to “ possibly or definitely related to intensive treatment, the risk of injurious falls was higher in the intensive vs conventional treatment group.”

What does this mean in the big picture to all of us?  The big picture remains confusing.  It is clear that lowering your blood pressure aggressively and intensively will reduce the number of heart attacks and strokes and kidney disease of a serious nature.  It is clear as well that any initiation or enhancing of your blood pressure regimen puts you at risk for a fall. You will need to stay especially well hydrated and change positions slowly during this immediate post change in therapy time period if you hope to avoid a fall.  Will more intensive control of your blood pressure at lower levels lead to signs and symptoms of dementia due to poor perfusion of your brain cells?  With the SPRINT study only running for three or more years it is probably too early to tell if the intensive therapy will lead to more cognitive dysfunction.

Antibiotic Associated Colitis Increases Risk

At least a half dozen times per week patient’s call with symptoms of a viral upper respiratory tract infection or present to the office for a visit with symptoms and signs of a cold.  These illnesses are caused by small viral particles which do not respond to antibiotic treatment.   Your body’s defense system attacks these viral particles and over a period of hours to days defeats them.   Despite years of ongoing public health announcements and handouts by doctors and nurses and attempts at patient education you find yourself negotiating with strong willed patients who want a “Z Pack” or some other antibiotic which they do not need.  “I know my body,” they argue.  “My northern or previous physician knew to always give me an antibiotic, why won’t you?”

The answer is quite simple. They do not work to shorten the course, intensity or duration of your illness. They do in fact put you at risk of developing complications of antibiotic use. When your infection requires the use of antibiotics to restore health, it is worth taking these risks. When you do not need the medication it definitely is not. This was confirmed by an article and research presented by E Erik Dubberke, MD of Washington University School of Medicine in Saint Louis, Missouri commenting on Medicare Data about the death rate associated with antibiotic related colitis infections due to Clostridia Difficile.  Bacteria normally reside in our large intestine and promote health and digestion.  When we prescribe an antibiotic it kills off the healthy and beneficial bacteria as well as the infection related bacteria. This destruction of healthy bacteria creates an environment conducive to “opportunistic “bacteria normally suppressed by the normal flora to invade and take over your gut. The resulting fever, cramping, diarrhea with blood occurs as the intestine become inflamed with colitis. One of the common opportunistic pathogens is Clostridia Difficile.

Dr. Dubberke looked at Medicare data and compared 175,000 patients older than 65 years of age and diagnosed with Clostridia difficile infection and compared them to 1.45 million control patients. He found that those with clostridia difficile infection had a 44% increased risk of death. When comparing admissions to nursing homes for treatment there was an 89% increased risk due to antibiotic related colitis care.

Antibiotics are wonderful when appropriate. They will always carry a risk of a side effect, adverse reaction or complication which is a risk worth taking in the correct setting.  It is clearly not worth the risk when your doctor tells you that it will not work.