Tuesday, June 15, 2010

Medical Malpractice Reform and the Feres Doctrine

Ever wonder why the government is so lukewarm towards medical malpractice reform despite overwhelming support of the medical community (17% of this country's GDP) and patients?  It's not necessarily because trial lawyers are the biggest contributors to President Obama and the rest of the Democratic Party.  Maybe it's because the government doesn't feel any pain from medical malpractice lawsuits thanks to its immunity from liability due to the Feres Doctrine. 

The Feres Doctrine came from a 1950 decision by the Supreme Court that prevents military personnel from suing the federal government for medical malpractice injuries that occur while being treated at military hospitals.  Thus the government is shielded from egregious acts of malpractice that most residents who rotate through VA hospitals are all too familiar with.

More and more cases of appalling deaths and injuries at our military hospitals are coming to light.  There is the case of the young man who was treated at Travis Air Force Base for appendicitis and died postop when he developed respiratory failure and was intubated down the esophagus by a CRNA.  Another service personnel was supposed to get a routine Cesarean section at Langley Air Force Base.  Her uterine artery was cut and the patient suffered a massive hemorrhage.  She was dead 12 hours later. A navy recruit training for submarine duty was improperly treated for pneumonia at a naval hospital in Bremerton, WA.  He ultimately endured removal of part of a lung and now has permanent brain damage.

There is a bill in front of Congress, H.R. 1478, that will allow military personnel to sue the government for medical malpractice.  The chances of the bill becoming law is pretty slim.  Says Jonathan Turley, law professor at George Washington University, "It would cost a huge amount of money to upgrade the military medical system to meet basic civilian standards. Congress simply doesn't want to spend the money."  An opponent of the bill, Rep. Randy Forbes of Virginia had this to say about the bill, "I don’t think the answer is always just having more litigation."

There you go, straight from a congressman's mouth.  The solution to medical negligence is not to have more lawsuits.  Somehow this enlightening philosophy only applies to the federal government, not the private medical community that continues to spend billions on clinically unnecessary defensive medicine, legal defenses, and exorbitant malpractice premiums.  Where are the trial lawyers?  Aren't they supposed to stand up for the defenseless little guy who has no recourse for his injuries except to file a lawsuit?  Or have they been exposed for what they really are, greedy ambulance chasers who are reluctant to bite the federal hand that feeds them?

Monday, June 14, 2010

A Real Piece of ... Work

Have you ever wondered about the humanity of your fellow citizens that share the road with you? The above picture was taken by a passerby shortly after an accident in Hermosa Beach, CA when a police officer rear ended the BMW convertible.  You can see the officer's legs sticking out the back seat and the driver inspecting the back of his car.

Not only does the driver seem to care more about the condition of his car than the health of the human being sprawled across his back seat, but the suspect, Brian Hitchcock, wrote some pretty inflammatory statements to the local newspaper.  First of all, Mr. Hitchcock denies being the driver of the car but he seems to know the driver really well.  Says Mr. Hitchcock, "The driver of the car, with 41 years experience, appeared stunned by the sudden intrusion of the officer landing behind him. It is not known whether he was injured by the flying officer." 

Mr. Hitchcock goes on to defend the driver in the accident as some sort of hero, "The driver of the car may have been scared out of his wits when officer Parente fired up his siren at point-blank range. Nevertheless, the driver's quick response allowed him to keep the car safely in its own lane, which avoided involving other motorists in the accident."  He also kindly points out that the rear driver in a back end collision is usually the one at fault under California law.  There is no inquiry by Mr. Hitchcock on the well being of the police officer or any signs of sympathy toward his injuries.

Police have noted that during a routine police stop a driver usually slows down and pulls to the right side of the road.  It is evident in the picture that the car was still in the middle of the road lane when the accident happened.  The police department is investigating  if the officer was riding too close to the vehicle when he collided, or whether the BMW driver deliberately stopped suddenly to cause the collision.  Luckily the police officer only suffered soft tissue injuries and is recuperating at home.

With Friends Like This...

Q. How politically impotent are physicians in this country?

A. When the most socialist president in recent history has to stand up for us to convince the Senate Republicans, our traditional allies, to prevent the 21% Medicare paycut that has already gone into effect June 1.

In President Obama's weekly radio address, he urged the senators to reverse the Medicare cuts and work toward a permanent solution to the insane SGR annual "adjustments" that have frozen physician reimbursements for the last 20 years despite ever rising expenses to treat patients.  But Obama didn't give this speech because he suddenly felt a personal bond between doctors and the Executive Branch.  He realized that if these cuts go through more doctors will opt out of Medicare itself, making medical access even more difficult for seniors.  With ObamaCare vowing to bring millions more patients into doctors' offices paying Medicare rates, he knows his program will be a failure if people wake up and understand this whole program is a sham, using wealth distribution that restricts medical access for all.

As for our so called "friends" in Congress, the Republican leadership decided that they would draw a line in the sand on further deficit spending right at the doctor's doorstep.  After trillions of dollars spent in the last couple of years for banks, brokerages, insurance companies, Fannie Mae, Freddie Mac, auto companies and their unions, home builders, used care dealers, appliances makers, profligate student loan borrowers, long term unemployed, two hot wars in the Middle East, and countless other federal programs, our Congressional allies finally found a constituency they felt they could ignore without fear of losing at the ballot box.  Yes cutting the salaries of doctors would make absolutely no difference to them in their ability to get reelected.  And that's the definition of political impotence.

Sunday, June 13, 2010

Pampered Pets

I saw this storefront at the local strip mall.  I find it quite amusing, if slightly appalling.  The sign says "Specializing in raw food diet for cats and dogs".  I didn't know raw food for pets needed its own specialty store.  I thought a raw food diet was whatever they find in the alleys and garbage cans.  It disturbs me that we have millions of people who go hungry in this country and around the world yet some people will spend money on pampering their pooch with a special raw food diet.  And don't get me started on pet food that advertise themselves as containing real meat and no fillers.  These pets eat better than many children in our urban or rural areas.  Is it any wonder people feel the gap between the poor and the wealthy in America is unbridgeable?  They figuratively don't live in the same country at all.

Better Lucky Than Good

In a follow up to the Abby Sunderland story, the 16 year old girl who was attempting to sail solo around the world before her boat floundered in the Indian Ocean was found alive and well by a search and rescue team.  The firestorm surrounding the parents' decision to let a minor child do this has not abated.  Her father has compared the risks of sailing solo for 13 months to the risks teens face when they drive.  Not many teenagers die sailing in remote oceans while thousands die every year behind the wheel.  I guess he has a point.

Saturday, June 12, 2010

CYA Anesthesia Record

The above image is representative of what's commonly called "railroad tracks".  It is an anesthesia record where the vital signs are perfectly stable and unvarying during the case.  Vital signs like these are considered ideal as it shows the anesthesiologist was maintaining the patient's physiologic state despite the surgeon's attempt at causing great harm and pain to the body.

Rarely do patient's vital signs stay this even, no matter the interventions of the anesthesiologist.  When a surgeon makes an incision, the blood pressure and heart rate rise due to activation of the sympathetic nervous system, not because the patient is "awake" or "light".  During the operation any large amount of sudden bleeding may cause the BP to fall.  Manipulation of internal organs can make the vital signs flutter erratically.  So achieving railroad tracks on an anesthesia record is pretty uncommon.

Except that I've noticed ever since residency that some anesthesiologists fudge a little on their records. I've seen records of cases where the patient could become extremely unstable, such as an aortic aneurysm repair or cardiac bypass and the vital signs hardly deviate despite major physiologic changes during the case.  I used to think that, wow, this anesthesiologist must be excellent.

Then someone told me that records like this are another form of defensive medicine.  If there are any problems with the patient later on, such as an MI or stroke, the anesthesiologist can point to his record and say that there were no problems during the case; any perioperative complication must have occurred outside the OR, shifting the blame to the surgical staff.  If an anesthesiologist has to give deposition for a malpractice case, he can point to his record and tell the lawyer that the patient was perfectly fine while under his care.  Thus the anesthesiologist will try to extricate himself from any suit. 

The beauty of this is that only the anesthesiologist is recording the vital signs in the operating room.  Everybody else is too busy with their assigned tasks to pay much attention to what's on the screen.  The anesthesiologist's recording is the last word on the patient's health during a case.  There is no audit system present.  Perhaps the advent of electronic record keeping in the OR will change all that.  Once it becomes wide spread it will be interesting to compare the electronic vs. manually recorded anesthesia records and see who really is an excellent anesthesiologist.

Thursday, June 10, 2010

What Price Glory?

Abby Sunderland, a 16 year old girl attempting to be the youngest solo sailor to circumnavigate the world, has lost radio contact in the Indian Ocean during a thunderstorm.  According to her blog, she had been sailing into winds clocked at 40-45 knots with 20 foot waves and water was getting into the engine compartment.  Her family is working with the American, French, and Australian search and rescue teams to try to relocate her.

I pray everything will turn out okay for Abby and her family.  But down inside I can't help but feel a sense of anger and rage at these people.  Seriously, SIXTEEN years old and she is allowed to sail solo around the world?  She's not even old enough to give a medical consent. What were her parents thinking?  On her blog, Abby says, "It has been my dream since I was 13 years old and began single-handing, to one day sail solo around the world."  Yes, well most teenagers have grand dreams.  Who hasn't dreamed of being the next Kobe Bryant, or the next president of the United States, or becoming a policeman, firefighter, doctor.  Teenagers are indeed highly ambitious.  That's why we have parents and teachers to help guide them. 

But the Sunderlands let their underaged girl sail solo around the world.  If she hadn't been caught in a storm, she could have been kidnapped and abused by pirates near Somalia, or suffered an unforeseen medical condition incapacitating her, or a thousand other calamities.  Just because her older brother Zac did the same trip doesn't mean she should do it too.  I can just hear their dinner conversation before she left home.  They may not have said it explicitly, but the fame of having two children each circumnavigate the globe solo was surely percolating in their minds.  The book deals! The movie premieres!  The trip to Oprah's couch!  They may say they are assisting their children in achieving their dreams but as grown adults their number one job was to protect the well being of their children.  This is almost as maddening as the death of Jessica Dubroff, the seven year old girl attempting to fly solo across the U.S. after just four months of flying experience.  She ultimately crashed near Cheyenne, Wyoming with her father in the back seat.  Let's hope Abby's fate meets a happier ending.

Anesthesia Induced Insanity

I saw this in my patient's H+P.  When presented with the option of anesthesia or no anesthesia, he risked insanity and agreed to anesthesia.  No problemo.

Thursday, June 3, 2010

Beware When A Dog Sniffs Your Crotch

French scientists have trained dogs to detect prostate cancer in the urine of patients.  They trained the dogs to sniff the urine of patients with healthy prostates and known prostate cancer.  Then they had the dogs do blind smelling tests of urine.  The dogs apparently became pretty good at it.  Out of 66 tests, the dogs were correct 63 times.  As many urologists will tell you, the PSA test that is the standard for detecting prostate cancer is not as accurate as we are led to believe. The next step is to understand the chemical that the dog is smelling to automate the process.  Otherwise every urologist's office will need to keep a dog on site to smell patients' urines. 

As an aside, this story reminds me of the episode in The X-Files where Scully discovered she had brain cancer when a monster targeted her for his next meal.  Again, life imitates art.

Tuesday, June 1, 2010

Canine Affection Or...

I saw this license plate at the local superstore.  This being Los Angeles, is the driver professing a fondness for man's best friend, or something a little more carnal?  Ha ha.