It’s Only a Cold …

As a concierge medical practice we pride ourselves on being available to help our patients with access to the doctor by phone and same day appointments. At this time of year we are faced with daily phone calls regarding cold or flu like symptoms.  Thus, I thought it appropriate to share some topical information which should be useful in helping anyone decide whether they should “ride out the storm” or give their doctor a call.

There are at least 1,500 different known viruses that lead to a viral upper respiratory tract infection sometimes known as “the common cold”.   With these, a high sustained fever of 101 degrees Fahrenheit is rare.  Aches and pains, nasal discharge with runny nose and post nasal drip are common. Dry cough advancing to a barking cough productive of clear, yellow and often greenish phlegm is common as well.  You’ll most likely feel miserable. Your sinus and head congestion make you feel like you are in a tunnel, a sound chamber, or wearing a deep sea diving helmet. Your appetite waxes and wanes. You are exhausted with the activities of daily living.  Getting out of bed to wash your face and groom yourself may seem as challenging as a 26.5 mile race up a hill.

Currently, there is no cure for the common cold. Antibiotics do not work.  A “Z Pack “does not speed up the process. An injection of antibiotic does not make it go away faster. The infection could care less if you have a high school reunion to go to in Philadelphia, a grandchild’s bar mitzvah or baptism, or a flight to Paris for a combined work/pleasure excursion. Frankly, once you have this type of viral infection you will most likely have to ride out the storm.

Furthermore, going to the ER and sitting and waiting to be seen doesn’t make the infection go away quicker. Paying for a visit at a walk in center or urgent care center where you are more likely to negotiate successfully for an unwarranted or needed antibiotic will not help either.

In most instances, your recovery from the virus will take 7-14 days providing you drink plenty of warm fluids, rest when you are tired and use common sense. Cough medicine may ease the cough. Saline nasal solution may clear the nasal congestion. Judicious use of a nasal decongestant under your physician’s supervision may help as well.  It will take time. You are contagious. No you should not go to the gym if you are feeling poorly. Chicken soup, tincture of time, hot tea with honey, plenty of rest and common sense are recommended remedies.

If at any point you still feel you have the plague, dengue fever, the bird flu or the Ebola virus come on in. We will take a look, evaluate your symptoms and likely tell you, “It’s a cold.”

Deep Vein Thrombosis Prophylaxis, Safety and the Joint Commission on Accreditation of Hospitals

Over the last few years, great emphasis has been placed on preventing blood clots from forming in the legs and pelvis of all hospitalized patients. These blood clots can break off and travel to the lungs causing life-threatening breathing problems and fatal heart arrhythmias and sudden death. Preventing these “venous thromboembolic events” has been a priority of quality organizations like the Joint Commission on Accreditation of Hospitals which inspect hospitals and offer certification if the hospital meets their criteria.

The movement to prevent these clots and sudden death has become so strong that you cannot admit a patient to the hospital without addressing these issues. Physicians must either choose to give injections below the skin with the blood thinner heparin three times a day or the low molecular weight heparin twice a day. You are additionally asked to prescribe mechanical compression stockings to the legs to further reduce the risk.

If you choose not to institute these orders you must clearly write out and outline your objections and reasons for not taking these measures. Even if you document your reasons for not instituting these measures you’re assured of receiving a call from your hospital’s quality care organization.

This all becomes newsworthy because two recent studies called into question the practices. One study concluded that mechanical compression stockings added nothing to the use of blood thinners in preventing deep vein clots. The other study cited that for every 1000 patients treated with blood thinners to prevent pulmonary emboli; you prevented three non-fatal pulmonary emboli at the expense of causing nine bleeding events – four of which are major.  I suspect this data will be discussed in our medical journals and at scholarly meetings and a consensus opinion will be reached on how to proceed. Letters will be written to journals criticizing the methods of these studies and other letters will be written defending them and, ultimately, a common sense approach will be reached.

In the meantime, it would be far more interesting to look at the Joint Commission on Accreditation of Hospitals and determine how they got so powerful that they can mandate procedures which may not have any value and may do harm?  Who are they?  How do they generate income and how much goes to who and why?

It is a fact that in the state of Florida, private insurers like Blue Cross Blue Shield, Aetna, Humana, will not contract with a hospital or institution unless it receives certification from this organization.  A study should be done to see if these JCAHO inspections costing $7-8 million dollars every other year resulted in any reduction of in-hospital errors, iatrogenic illnesses, death rates and serious illness?

Insurers and employers who pick up the “lion’s share” of our health care costs are always asking for accountability and efficiency and want to pay for what works. It would be nice to know if their relationship with JCAHO has made the patient safer or healthier over the last 15 years.

The 20 Minute Rule

To meet Federal patient satisfaction goals, our hospital administration is requiring community based physicians to give patient admission orders before we have a chance to see the patient. Patients who self-refer themselves to the emergency department, are evaluated by the emergency room staff, and who are determined to require admission must be admitted by their community physician within 20 minutes of receiving a call from the ER staff advising the patient requires admission. In most cases, the community physicians have no idea the patient is actually at the ER until they receive that call.

It is bad medicine to issue patient orders on a patient you have not seen, taken a history from or performed an examination on. To complicate matters, the hospital does not require physicians to actually come in and see the patient for 12 hours after admission.   Think about it, diagnostic and care orders are being given routinely by doctors who have not examined the patient. The doctors then have the latitude to not show up for half a day to actually do an onsite evaluation.

One of the cardinal rules of medical training is you should do a thorough history and exam before constructing a theory of the causes of an illness and instituting diagnostic and therapeutic measures. The local hospital rule is a direct effort of the hospital to control all aspects of patient care for financial gain. They are buying up practices, revamping medical staff bylaws by manipulating the rules and, filling the decision making committees and legislative physician groups with salaried doctors they control.

Hospitals perceive community based physicians who are advocates for their patients as a threat to their financial planning.  The goal is to drive out the community based physicians because they act as a check and balance to the designs of the hospital system working as advocates of their patients. Do not believe for one moment that the goals and aspirations of patients in a community setting are aligned with the goals and aspirations of hospital administration.

I recommend that citizens look into the politics of their local hospital system.  If you do not, you may find that your doctor can no longer take care of you when you are sickest and in need of those professional services provided by someone who knows you well. You may find that you are transported from the ER to the floor quickly but you may not get to see a doctor for half a day.

How should this policy be altered to make sense?  Staff physicians should have 90 minutes to arrive at the ER and assume the care of their patients. In critical life threatening situations requiring immediate intervention, hospital ER staff should be providing stabilizing care until the patient’s care team arrives.

Requiring doctors to give orders on patients they have not seen is bad medicine. Giving those same doctors 12 hours to show up is irresponsible.

The Turnovers are the Difference- Medical “Handoffs” Are Continually Fumbled

This is a humbling football season for those of us who root for Florida teams at the collegiate or professional level. It seems that each week after another loss we are listening to the head coach standing at the podium during a post-loss press conference talking about how if the handoffs had not been fumbled, and the ball dropped and lost, his team could have prevailed. It is hard enough to deal with the turnovers and fumbles when rooting for your team. It is far more difficult to deal with it when we are talking about human beings hospitalized and cared for by hospital employed physicians and then turned back to the community without communicating adequately, or at all, with the care team responsible for their continued care at the community level.

Take the case of GH, an 82 year old obese diabetic with high blood pressure, high cholesterol and heart irregularities requiring the use of Coumadin to prevent a stroke. He awoke one morning two weeks after a major auto fender bender and found his underwear stained in bright red and dark brown blood. His wife was unsure if it was coming from his rectum or penis so she called 911 and allowed the patient to be taken to the nearest emergency department.  He was seen by the emergency room staff and admitted to their contracted hospitalist service for presumed intestinal bleeding due to Coumadin toxicity.

Eight days later he was discharged home with an indwelling Foley catheter needed because of the “clots” in his bladder. His Coumadin had been stopped on admission and never restarted. GH could not get out of the bed and walk while in the hospital and he stubbornly refused to go to a nursing rehabilitation center as an interim step until he was strong enough to walk independently.  His frail 80 year old wife, battling a lymphoma herself, was given the task of caring for this obstinate man at home and emptying and caring for his indwelling urinary catheter.

On his first day back home, I received a phone call from his wife informing me of this. She didn’t know what she could possibly do to care for him because he weighed 230 lbs and he couldn’t get out of bed and walk. A nursing service and physical therapist had been requested but had not yet called to schedule a visit.  She was particularly disturbed because 12 hours had gone by since he got home with no urine appearing in the bladder drainage catheter. At the same time his lower abdomen was growing in size and he was feeling pain and discomfort at that spot.  Once again, 911 was called and he was taken back to the same emergency department. Paramedics transport sick patients to the geographically closest facility not necessarily the one his physician sees patients at.

GH was readmitted because his catheter was blocked with clots and needed irrigation and there were concerns about a urine infection. I spoke with the wife and children and asked for the name of his doctor but they could not remember it. They did remember the name of his consulting urologist. I called the urologist who was a bit put out to discuss the case with me. He told me that “our“ patient was bleeding from the urinary tract due to a transitional cell cancer of the bladder that he discovered and treated during a cystoscopy. He felt the prognosis was excellent.

The urologist declined to discuss whether the patient was additionally bleeding from his intestinal tract or if the appropriate evaluation had been done. He suggested I find the hospitalist responsible for the patient’s care. When I asked for the name of the hospitalist he told me he had no idea who it was. “They all look the same to me,” was his actual response.

I asked the patient’s wife to have her husband sign an authorization to release medical records and obtain the medical records of his admissions for my review. She did that and presented it to the medical records department who sent me a brief summary of his second admission. It took three phone calls to obtain the records of the first admission and another to get the emergency department records.  I needed this material because it was quite easy to convince the patient to come to a local rehab facility after this hospitalization with me as his attending physician.  The patient and family had no idea why he was bleeding other than “I had clots” in the bladder. They didn’t know the name of his hospitalist either.  When I received the records it identified the physician. I called the hospital to page her but was told she was “off “for the next few days. Her colleagues on duty did not know or remember the patient.

The patient records finally arrived. His admission diagnosis was bleeding due to Coumadin toxicity, but the INR (a measure of how effective the Coumadin is in thinning the blood) was very low indicating that his blood was not anticoagulated much at all.  An INR of 1.4 doesn’t cause bleeding and is not toxic. The medical record said he had hematochezia (blood in his stool) but there was no documentation that anyone had performed a rectal exam or examined a stool specimen for the presence of gross or microscopic blood.

There was a lab order to type and cross-match the patient for a blood transfusion but certainly no mention that a transfusion had actually occurred. There was a thorough procedure note from a gastroenterologist who looked in his stomach and colon several days after admission and found no source of bleeding. I called the gastroenterologist on the day I received the records but he was gone for the Thanksgiving weekend.  The records indicated the patient’s blood count showed hemoglobin of 9.3 on the day prior to discharge and 8.3 on the day of discharge but there was no mention of an investigation of why the blood count dropped and why he was released with a dropping blood count.  A chest x-ray report on his first admission showed a right lower lung infiltrate but there was no follow-up performed or reported.

The patient arrived at the local rehab facility on Thanksgiving morning. I saw him and performed a thorough history, review of his records and an exam.  He was no longer bleeding, with no black stools noted on my rectal exam and no microscopic blood on the stool occult blood slide test I performed at the bedside. His Foley catheter was draining clear non bloody urine and the patient looked pale but well.

It was really very easy to convince this patient to come to rehab to learn to walk again once I became aware of his hospitalization and condition.  After my initial exam I sat down with the charge nurse and we constructed a care plan for the next few weeks at the rehab facility and explained it to the patient. Then I told the patient he had bladder cancer with a good prognosis. He was completely unaware of that diagnosis until we had the conversation.  I called his wife and children separately and reviewed the diagnoses and care plans for follow-up.

GH entered the hospital on an emergency basis as an unknown. He was appropriately taken to the nearest receiving facility by the paramedics when he was found to be on a blood thinner and bleeding actively.  His inpatient hospital employed physicians prevented a catastrophe and did what was necessary to make sure one was not ongoing. They did little or nothing to insure the loose ends of his medical problems resulting in hospital admission were addressed or understood by the patient and family.  Little or no effort was made to insure continuity of care and appropriate follow-up.

Judging by the editorials in our peer reviewed medical journals, this has become the norm not the exception in our insurance company / employer driven health care system. The devil is in the details. Unless the loose ends are planned for , understood and addressed, patients like this will continue to be bounced back to the hospital as an “emergency”, unnecessarily spending money we do not have and do not need to waste.

Lancet Study Emphasizes Long Term Benefit and Safety of Statin Use

Richard Bulbulia, MD, of the Heart Protection Study Group reported in the Lancet that statin medications are safe and effective over long periods of time.  They looked at 20,536 patients at high risk for vascular events. They studied patients who were between 40 and 80 years old. These patients were randomized to one group receiving Simvastatin (Zocor) daily at the 40 mg dose or placebo for 5.3 years. They were then followed for another six years during which both groups received the statin.

Researchers found that during the initial 5.3 years of the study there was a 23% decrease in major vascular events and an 18% reduction in vascular mortality in the Simvastatin treated group.

They also looked at complications of therapy over the eleven year period and concluded, “Reassuringly, there was no evidence that any adverse effect on particular causes of non–vascular mortality or major morbidity, including site-specific cancer, was emerging during this prolonged follow-up period.”  In an editorial in the same edition, Payal Kohli, MD and Christopher Cannon, MD of the Brigham and Women’s Hospital in Boston said the results “provide contemporary and confirmatory evidence that extended use of statins is safe with respect to possible risk of cancer and non-vascular mortality.”

It is noted that the dosages used are higher than what the FDA currently recommends for Simvastatin due to the risk of muscle injury at higher doses. Despite that, the Lancet editorialists concluded that “concerns should be put to rest and doctors should feel reassured about the long-term safety of this life saving treatment for patients at increased cardiovascular risk.”

A Treasure Lost – Surgeon, David Wulkan, M.D.

I lost a colleague this week to acute leukemia. He was diagnosed and treated at a world class Center of Excellence but succumbed to the complications of treatment so rapidly that those of us who worked with him daily had little knowledge that he was ill or gone until it was all over.  This 56 year old General and Vascular surgeon shared a February 17^th birthday with me, came from a working class urban background and trained in the General Surgery program at the rigorous and demanding University of Miami Jackson Memorial Hospital Program. He completed his residency training several years after I completed my general medical training and then moved up to Boca Raton, Florida to join one of the premier surgical groups in the area.

My wife had the privilege of teaching one of his children at the pre-school level and knew his wife and children. We never broke bread together or visited each other in our respective homes. We didn’t go out socially together either. Despite this, I considered him a friend as I saw him on a daily basis while I made morning and evening rounds at the Boca Raton Community Hospital as we both strove to prevent disease and help others. He was warm, understanding, even-tempered, showed great judgment clinically and great understanding of his patients’ needs and concerns.

Surgeons are often branded as arrogant, cold, and volatile. Dave was like a teddy bear, just a very bright talented competent one.  We shared patients and they all thanked me for finding them such a special physician in their time of need. He educated me when I needed to be educated and he did it in a manner that conveyed the message in a professional and respectful way without making me feel like I should have known that.

I know the kind of hours he put in and the sacrifices his wife and children made with regard to time so that he could care for other persons’ loved ones. That is time one never recaptures.

My community has lost a treasure of a doctor and a wonderful human being. We will miss his kind and affable manner, wisdom and skill. My thoughts and prayers will be with him and his family and with the families of all those other caregivers who make it easier for their loved one to care for and help someone else’s loved one routinely.

I was proud to be Dr. Wulkan’s colleague and will miss him greatly.

Low Dose Zolpidem (Ambien) for Middle of the Night Awakening

Staying asleep and getting back to sleep after awakening are major issues for seniors.   In the past, physicians were counseled not to use drugs like Zolpidem (Ambien) unless a user had a good 7- 8 hours after taking the drug to remain in bed and rest while the product is metabolized and leaves their body.  The drug is relatively long acting and has been associated with sleep walking, day time sleepiness, falling and motor vehicle accidents especially when the user takes them in the middle of the night and awakens early for activities. Seniors are particularly prone to night time awakening for toileting activities, aches and pains and other issues.

The FDA has just approved a low dose version of Zolpidem for those patients who awaken in the middle of the night and cannot get back to sleep.  It is manufactured under the brand name Intermezzo in doses of 1.75 mg for women and 3.5 mg for men. The difference in dosing is based on the difference in the speed at which men and women metabolize the drug.

I am advising my patients to please be patient and allow us to evaluate how this product performs in large numbers of human subjects. The original studies were performed on 375 patients. It will be interesting to see if this product will be appropriate for overnight airplane travelers on four and five hour plane flights as well.

Proper Disposal of Medications- South Palm Beach County

Self disposal of prescription medications is becoming a major problem. Water is being contaminated with prescription drugs.  Recently, researchers found traces of Prozac in fresh water fish and shell fish.

The City of Delray Beach and the Delray Beach Police Department will be providing a public service by disposing of your unwanted medications. They have placed a “Med Return“ receptacle in their lobby at 300 W. Atlantic Avenue.

You can phone 561.241.7888 for more information.

Generic Drugs- Small Government and Less Regulation Lead to Lack of a Safety Net in Production

Years ago under pressure from consumer groups, Congress dramatically reduced the time a drug manufacturer could retain a patent on a brand drug.  The patent was reduced from 21 years from release of the product after FDA approval to 7 years from the time development begins. The extremely short window of opportunity to research and develop new medications led to extraordinarily high prices for the new medications. The law met its intended result of encouraging the rise of copy cat less expensive generic drugs.

At the same time under the Reagan Administration, the Food and Drug Administration closed its research and evaluation labs for testing new pharmaceutical products before they can be released to the American public. Under the new laws, pharmaceutical manufacturers now can contract with outside labs to test their products and the reports are then submitted to the FDA for review and approval.  No longer did a drug company have to submit its actual product to the FDA for their independent testing and approval or denial.

The results of these two pieces of government de-regulation was the rise of generic pharmaceutical manufacturing plants in remote regions of China , India and Asia with the most reliable and technologically advanced plants in Israel. Generics needed to prove to the FDA that they possessed 85% of the bioavailability of the brand product in reports generated by contracted labs and sent to the FDA for the products approval.

For years I suggested to my patients that if they could afford the brand name they were best served paying the higher price to obtain a product they knew was produced locally with relatively high standards.  The NY Times on Saturday August 13, 2011 ran a front page article noting that over 80% of generic products are produced in “shadowy” foreign factories that have never ever been inspected.  Several years ago 81 individuals perished because Chinese manufacturers substituted cheaper and tainted products in the making of the anti coagulant heparin. Counterfeit packaging and products originating with the Russian mob proliferate throughout the world market and are difficult for experts to distinguish from the real thing.

It appears that the Obama administration has finally reached an agreement with the generic drug industry for the industry to pay for government inspection of their facilities every few years. The legislation may pass through Congress this fall.

My suggestion to my patients remains the same. If you can afford the brand product purchase it. Know where your pills come from. Demand that your Congressional elected official works to fund the FDA so it can reopen its research and evaluation lab and be the independent agent determining the safety and efficacy of the drugs we are prescribed. Consider extending the length of a patent on new products in exchange for lower pricing on brand name drugs. It’s time to stop allowing only market forces to be watching out for the safety of our medications. That’s like asking the fox to watch the hen house.

Strolling After Dinner Wards Off Peripheral Arterial Vascular Disease Risk

Healthy lifestyles with excellent food choices and regular physical activity have been encouraged as the secret to a long and healthy life for years.  The U.S Department of Health and Human Services has promoted and encouraged every adult to get up to 90 minutes of exercise per day to stay healthy.  This type of time commitment is difficult for many active working adults to achieve.

In an article published recently in the Journal of Vascular Surgery, Stanford researchers point out that you just might be able to protect yourself against peripheral arterial vascular disease with a much more modest evening stroll. They noted that “a lifetime of even light exercise not only protects the heart but also the legs, reducing the risk of peripheral arterial disease (PAD).”

According to John P. Cooke, M.D., PhD of Stanford University Medical Center, a sedentary lifestyle predicted a 46% higher risk of peripheral arterial disease compared with a lifetime of recreational activity of any intensity. The biggest gains in PAD protection came in people who went from virtually no physical activity to minimal activity. “Even light activity, such as strolling, is enough to protect against PAD.” According to Dr. Cooke “ Get up off the couch, go for a walk, and you will be less likely to have problems in the future.”

Cooke and his group at Stanford looked at 1,381 patients and noted that inactive patients were nearly twice as likely to have PAD as those who had active lives. While inactivity is a risk factor in developing PAD other controllable risk factors exist and should be modified. These would include tobacco use, elevated blood sugars and elevated triglyceride levels. Once individuals develop narrowing of the peripheral arteries producing pain on exertion called claudication, their activity becomes limited by the pain.

The message is clear.  Stop smoking and start walking – even if the walk is a slow relaxing stroll.