The soda pop blues

"Just when I thought I had heard it all." That's one of my favorite lines and it never ceases to amaze me how many times I come across something new that I had never heard of before. Now, as a backdrop to this story, I tend to drink more than my fair share of soda, but hey, we all have our vices right? Well, I thought I drank a lot a lot of soda but recently met someone who was consuming two, two-liter bottles of soda a day. So, you may think that would case weight gain, right? Yes, it did. Acid reflux? Yes? But guess what else happened? The acid ate away so much at this person's esophagus that it caused it to rupture! Can you imagine that happening to you?! Good grief.

It's Gotta Be the Shoes

As the snow falls down from the dark winter sky here in good old Syracuse, New York, it reminds me of a night over 10 years ago when I was playing an intramural basketball game in college. I had purchased a new pair of sneakers that day and wore them to the game. They felt a bit snug but nothing too out of the ordinary. There was a lot of running and stopping as is typical in a fast paced game of this sort. My toes were starting to hurt, but I figured it was just normal soreness from the new shoes and played through the discomfort. But finally, I had to stop. I sat down and took my shoes off and thought I would just re-adjust things to make the sneakers more comfortable. But as I tried to get the shoes back on, I could not do so because of the pain. Confused, I pulled off my socks to get a better look at my toes and I was aghast at what I saw. Both big toenails were literally purple and pushed up from the accumulated blood underneath the nail. Turns out, the blood had actually clotted under both nails due to the tight fitting shoes and constant stopping of my feet, which was jamming my big toes up against the front of the shoe, repeatedly traumatizing them.

It was late and everyone I knew had left as I sat there trying to figure out what to do next. I figured I would just go back to my room and that this would slowly go away. But then I realized this wasn't going to go away any time soon and that I needed medical help. I thought I would be able to fight through the pain and put my feet in the shoes but it was just impossible, no matter how hard I tried. My car was parked deep in the lot on a cold snowy night, and I had no choice. I walked barefoot all the way through the snow to my car. As you can imagine, that was not a fun experience. There was no point wearing the socks over my feet because they were already wet.

I arrived at the local urgent care center and the doctor took a look. He said he was going to take a hot needle and stick it through my toenail to relieve the pressure and let the blood come out. The funny thing was that I normally would associate this with being painful but I was in so much pain from the blood underneath the toenails that the feeling of the needle going through the nail was actually the best feeling in the world at the time and did not hurt a bit due to the relief it provided. The nails fell off a few weeks later and grew back later. So let this be a lesson to people out there to avoid wearing sneakers for the first time during a new game. Walk around in them first to break them in.

We never looked

It's amazing the kind of things that get written in medical records that never actually happened. For those following this blog for the past week, you know that my son was in the hospital following some complications after a tonsillectomy and adenoidectomy. Either myself or my wife was with him at all times. We know for sure that no one ever checked inside his nose or his ears, yet somehow the discharge summary states the nose and ears were clear. No one did any evaluation of his eye movements yet the records indicate this was formally evaluated. These are not huge deals, but still highlight the point that what the records say happened did not necessarily happen. This is important because some people hold the medical records up to be a flawless document that cannot be wrong. As someone who reads through an unbelievable amount of records every month, I can tell you that almost every case has some type of error. Most patients never know because they never get their hospital records. Some of the errors I have read include two different doctors saying the injury involves different sides of the body, inaccurate time sequences, and my favorite: stating something is non-contributory or "WNL."

I recently had a case where all the medical records stated that family medical history was non-contributory. This basically means that the family medical history is not important or relevant to the patient's current state. But what often happens is that health care providers do not ask about the family medical history and just say that it is non-contributory when this is not the case. In the case mentioned above, I had forgotten to ask about family medical history. I wasn't comfortable with relying on the medical records saying the family medical history was non-contributory so I called the patient at home and asked her about this. As it turns out, she had first degree relatives with posttraumatic stress disorder, heart attack, hypertension, diabetes mellitus, and cardiac bypass surgery. Yep, that's non-contributory all right. Unbelievable. It kind of reminds me of the phrase "WNL" when neurologists examine the cranial nerves. This abbreviation is supposed to mean "within normal limits." I am starting to think that it sometimes means 'We never looked."

If you want

These last few days have been crazy which is why there have not been recent blog postings. Although my son was feeling better and came home, he has been in the hospital since Saturday due to dehydration and fever. He basically refuses to drink after having the adenoids and tonsils removed. I am too exhausted to write a long post tonight, but I found one of the events during our stay rather incredible so I thought I would pass it along since it is brief. When my son was first discharged, the surgeon placed him on 7 days of oral antibiotics. We were giving him this to him until he was re-admitted. When he went up to the main floor from the ER, we asked if he was going to get his antibiotic again. The ENT resident said that they normally do not send children home with antibiotics after these procedures so he didn't think he needed it. I don't know if this is true or not, but I then said that the attending had ordered it because he felt he DID need it. So the ENT resident just looked at us and non-chalantly said, 'Well, ok…if you want." To me, that is just a baffling response. If I want?! Isn't it the job of the doctor to determine the need for the medication? In this case, the attending doctor had already ordered it, the resident didn't seem aware of this, and then we mentioned that point it seems "If you want" was a face-saving response. One day later, the pharmacy finally sent up the antibiotic and he took it tonight. Kind of strange that it takes a day to send up one of the most common antibiotics in existence. OK, stay tuned for more tomorrow.

A Tale of Two Residents

So yesterday, we returned to the hospital for our other child's tonsillectomy and adenoidectomy procedure. We were more worried about this one because he is younger. To read about the positive and negative aspects of our first experiences, please read the Tonsillectomy tales 4-part series. Everything pretty much went well except for a ridiculous situation that occurred shortly after the surgery. My son (who is only two and a half) did not wake up from the anesthesia in a pleasant state. He was crying, screaming, arching his back, and squirming. Of course, the nurse on the floor didn't have the orders for pain meds from the nurse who was with him in the recovery room. This is one of the most annoying and common things that happens upon a transfer to a new floor and can so easily be corrected by implementing an efficient system. How about this idea? Don't transfer a patient to a new floor UNTIL the floor has all the orders for the medications. Sheesh.

Anyway, in the midst of this chaos, a meek lady with a white lab coat walks in and just starts asking medical questions. If anyone has read this blog before, you know that I cannot stand this. Medical professionals need to introduce themselves when they walk in a room. So my answer to her first question was "Who are you?" She apologized and said she was the pediatrics resident and asked a bunch of questions that didn't seem to us to have much bearing on the situation at hand. We asked about why my son was making unusual gasping breaths ever since he woke up and she said it was because he was crying. We said that he was making these breaths before he started crying. She then said it was probably hiccups. My wife, who is a registered nurse, said there was no way it was hiccups because she felt him pressed against her body and could tell. The resident then said that it was probably due to the anethesia. I could tell she was just giving that answer to say something but really had no clue what was going on. So I challenged her on it and said "Have you ever seen this after aneshesia before?" She paused and said, "Maybe once." That's nice. Then how can that be thrown out so cavalierly as the explanation?! If you don' know, say you don't know, and get someone who may know such as a senior resident or attending physician.

After 15-minutes of needless screaming, the nurse finally comes in with two syringes. One had Tylenol. Another had codeine. Within 5 minutes, my son's face started to swell and get red, as did both of his arms. We told the pediatrics resident about this and she said that it was probably because he was crying. Oh no, I thought, here we go again. So I had to point out that these were new findings since the codeine and that it may be an allergic reaction. She said it may be from the anesthesia. Sighhhh. I again explained that the symptoms just started as soon as he took codeine and that he never took codeine before. I then suggested the possibility of an anti-allergy medication and she said she agreed and would order Benadryl. I sat there amazed that here I am as a non-MD having to lead an MD to figure out what is happening here. So then the nurse walks in and I asked if she had the Benadryl. She said she saw the resident in the hall who just said they are not going to use Benadryl. Ummmmm. Do you think the resident ever informed me of this? Nope. I was of course aggravated at this but then the ENT resident walked in.

What a difference. His first comment to my wife and I was "You two know your child better than anyone and you are the first line of defense." OK, so instantly he is acknowledging we have some insights that need to be listened to since after all, we are his parents. Good. Then he demonstrated he was taking our complaints seriously, examined my son, acknowledged this could be an allergy to codeine, explained the pros and cons of Benadryl at that stage, and assured us this would be appropriately and closely monitored. He also said that he was in charge here and not the pediatrics resident since this was an ENT patient. He also said he would have his senior resident come down to take a look just to be sure. Two different residents, the same exact situation, and both handled in polar opposite ways. What a relief it was to have the ENT resident and I felt very comfortable at that point. We decided not to use the Benadryl in favor of observation. In reality, this story has nothing to do with Benadryl, but has everything to do with communication and coming across professionally. Eventually, the symptoms went away and the breathing problems stopped. Today, my little buddy was having fun scooting around the house on his fire truck. :)

Stupid interviewing techniques

I had a case recently of a person who went to the hospital with a sudden onset of stroke symptoms. In addition to having expressive language impairment at the time she was also confused and understandably anxious. She was alone and the physicians tried to obtain information from her, which included the estimated time that symptoms began, personal medical history, and family medical history. This is all well and good, provided that it is written in the patient's records that the information was obtained from the patient in an acute confusional state. But it wasn't. The history was reported as if that was the actual true history.

The patient saw what was in the records for the first time when I reviewed them during my own detailed interview. At almost every turn, she said that information in the records was simply not true and emphasized she was interviewed alone in a confused state. This is why when I write reports, I use phrases such as "the patient reported" or "the patient stated." This way, it is clear where the information is coming from. If I have a patient that cannot provide a good history, there are no medical records, and no reliable informants to contact, then I will note that "the patient appears to be a poor historian and therefore the history provided cannot be relied upon as necessarily being accurate." Simple as that. It just amazes me that people cannot use common sense and realize that the information obtained from someone in an acute confusional condition may not be right, and to list in the medical records as if the information is factual is just plain silly.

Drug reps and the bribing of the modern U.S. physician

Yesterday, I was reading a fascinating inside story
about the life of a psychiatrist who became drug rep, or as some politically correct people would say -- a pharmaceutical salesperson. The psychiatrist wasn't literally selling the medications but he was providing the sales pitch that led to the sale in the end. The article raised many interesting ethical issues and brought to mind that this was a topic I had some strong opinions on yet never voiced on this blog before. So, here we go….

The bottom line to me is that the practice of giving doctors gifts in exchange for a chance to swindle them into selling a certain medication should be illegal. Told you I had a strong opinion on this. For me, it’s a matter of common sense. We are talking about people's health and treatment decisions such as medication selection should be based on the experience of the physician and objective research data. It should not be because I feel like I owe Joe the drug rep for the 10 pepperoni pizzas he just brought by to feed me and my residents.

I am a neuropsychologist and I do not prescribe medications. Despite this, in all of the medical settings I have trained in, I was always encouraged by the drug rep to attend the talk. Now why would that be? Because psychologists are prescribing medications in some states such as New Mexico and they know it is just a matter of time before this happens in more states than not. So why not build the relationships early, they figure. They do not know that I have no intent to prescribe medication one day, but there may also be another reason why they wanted me to attend. Believe it or not, physicians are always asking neuropsychologists what medication they recommend for certain conditions. Knowing this, the drug reps want to get the word out on their medication to as many people as possible. Or maybe they just want me to grab some of the promotional materials and distribute them so as many patients see these as possible and see it as a possible endorsement of the medication.

To those outside the medical community, here is the typical situation: A meticulously dressed young male or female, usually quite attractive, arrives to the hospital with a room set aside to do a talk on a specific medication. The drug rep spends time prepping the room, making sure the food is there and that promotional materials are spread out everywhere. So when you eat the food for the "Wonder-drug" you best believe you will be eating it on a Wonder-drug plate, wiping your face with a Wonder-drug napkin, and drinking from a Wonderdrug cup. You'll be taking notes with your very elegant and shiny looking Wonder-drug pen on some very fancy Wonder-drug paper. You may be slightly distracted by the Wonder-drug clock you received, or maybe you'll be busy reading the pamphlet of glossy Wonder-drug propaganda sheets you were handed about the medication. You'll hear some of the presentation, but you'll probably be distracted by going up for seconds in the lunch line since the selection of food and the quality of it is ten times better then anything the best chef can hope to serve up in the hospital cafeteria.

Physicians do not have a lot of time to read research independently, but they need to make the time. If they don't and they rely on their information from biased sources who have essentially bribed them, how are the patients supposed to benefit? If anyone thinks bribe is too strong a word, consider that there used to be (and maybe there still are) programs in which physicians can earn points for how many of a certain medication prescribed. Earn more points and you get a bigger gift, such as a trip to the Bahamas. How is that not corrupting? Is any physician doing this with bad intentions? I doubt it. But do many physicians have their eyes closed as to how they are being manipulated, however so subtly? Probably not, or if they do, the thoughts are likely minimized. Also, not all physicians attend these lunches and some are able to see through the fog. But too many are not and it those physicians that concern me. As a patient, how am I to know? The only answer is to make it illegal for drug reps to provide gift-based lunches when trying to sell a medication. Can't make it illegal. Then have the American Medical Association implement this into the ethical code. Oh, sorry, can't do that because they are making millions off providing the drug companies ways to identify physicians and their prescribing habits. Click the story in the first paragraph to read more.

Lastly, I am not opposed to drug reps speaking to physicians, but it needs to be done without any type of gifts. Just come by, let people bring their own lunches again (gasp!), do the talk, take some questions, and end any sense of impropriety.