Archive for the ‘medicine’ Category

Case #1 Ebola

Saturday, October 4th, 2014

The early information of the Ebola patients in Dallas seems to suggest that competence has not been high on the list of priorities. First, the patent seems to have known about his illness before he got on the plane to the US. He lied to the authorities in Liberia but that is not that unusual. All it takes is ibuprofen to evade the screening at the airport.

Second the treatment of the relatives Has finally become humane after days of cruel treatment including quarantine in a contaminated apartment.

The initial treatment was not a model of infectious disease protocol. Why he was sent home with a GI illness and a history of travel to Liberia is still not explained. My medical students are all told to take a history of travel with any GI illness symptom. It’s not clear who he saw but many ERs use Nurse practitioners or PAs to see ER patients.

He is not doing well and he seems to be declining. We will see how he does but his relatives are still in serious trouble. We are still in trouble.

The promised treatment program is still inadequate. Tomorrow will bring more bad news.

A CDC official said the agency realized that many hospitals remain confused and unsure about how they are supposed to react when a suspected patient shows up. The agency sent additional guidance to health-care facilities around the country this week, just as it has numerous times in recent months, on everything from training personnel to spot the symptoms of Ebola to using protective gear.

This is only the first case.

UPDATE: More news from Bookworm.

Ebola can transmit through people’s skin. It’s not enough to keep your hands away from your nose and mouth. If someone’s infected blood, vomit, fecal matter, semen, spit, or sweat just touches you, you can become infected. Even picking up a stained sheet can pass the infection. Additionally, scientists do not know how long the virus will survive on a surface once it’s become dehydrated. The current guess is that Ebola, unlike other viruses, can survive for quite a while away from its original host.

Oh oh. This explains the infection of hospital workers in Nigeria from urine.

The good news, if any, is this:

If patients get Western medicine that treats the symptoms — drugs to reduce fever and to control vomiting and diarrhea, proper treatment if the body goes into shock, and blood transfusions — the mortality rate is “only” 25% — which is still high, but is significantly lower than the 70%-90% morality in Africa, where patients get little to no treatment.

I will update this as news becomes available.

UPDATE #2

Now we have a possible case #2

A patient with Ebola-like symptoms is being treated at Howard University Hospital in Washington, D.C., a hospital spokesperson confirmed late Friday morning.

The patient had traveled to Nigeria recently.

That person has been admitted to the hospital in stable condition, and is being isolated. The medical team is working with the CDC and other authorities to monitor the patient’s condition.

“In an abundance of caution, we have activated the appropriate infection control protocols, including isolating the patient,” said hospital spokesperson Kerry-Ann Hamilton in a statement. “Our medical team continues to evaluate and monitor progress in close collaboration with the CDC and the Department of Health.”

No final word yet. Then, of course, we have the NBC case.

Thursday, news broke that a freelance NBC cameraman covering the outbreak in Monrovia, Liberia had tested positive for Ebola after experiencing symptoms of the disease.

The cameraman, Ashoka Mukpo, had been working with chief medical correspondent Dr. Nancy Snyderman. NBC News is flying Mukpo and the entire team back to the U.S. so Mukpo can be treated and the team can be quarantined for 21 days.

Is Ebola airborne ?

Saturday, September 13th, 2014

Ebola has become an uncontrolled epidemic in Africa. I have previously posted on Ebola elsewhere.

UPDATE: There is now a conclusion that Liberia and Sierra Leone are lost.

But Jonas Schmidt-Chanasit of the Bernhard Nocht Institute for Tropical Medicine in Hamburg told DW that he is losing hope, that Sierra Leone and Liberia will receive the neccessary aid in time. Those are two of the countries worst hit by the recent Ebola epidemic.
“The right time to get this epidemic under control in these countries has been missed,” he said. That time was May and June. “Now it will be much more difficult.”
Schmidt-Chanasit expects the virus will “become endemic” in this part of the world, if no massive assistence arrives.

This is from a German source. Our own CDC will not yet say this.

In the balance therefore, the probability is that the virus is not airborne — yet — but it is more dangerous than its predecessors. This would account for its ability to slip through the protocols designed for less deadly strains of the disease. It’s not World War E time, but it’s time to worry.

And: This may be a new strain with more virulence.

The results of full genetic sequencing suggest that the outbreak in Guinea isn’t related to others that have occurred elsewhere in Africa, according to an international team that published its findings online in the New England Journal of Medicine (NEJM). That report was from April 2014.

Now, we have more news. From 2012, we know transmission in animals may be airborne.

While primates develop systemic infection associated with immune dysregulation resulting in severe hemorrhagic fever, the EBOV infection in swine affects mainly respiratory tract, implicating a potential for airborne transmission of ZEBOV2, 6. Contact exposure is considered to be the most important route of infection with EBOV in primates7, although there are reports suggesting or suspecting aerosol transmission of EBOV from NHP to NHP8, 9, 10, or in humans based on epidemiological observations11. The present study was design to evaluate EBOV transmission from experimentally infected piglets to NHPs without direct contact.

The study of this potential explosive development showed:

The present study provides evidence that infected pigs can efficiently transmit ZEBOV to NHPs in conditions resembling farm setting. Our findings support the hypothesis that airborne transmission may contribute to ZEBOV spread, specifically from pigs to primates, and may need to be considered in assessing transmission from animals to humans in general.

Now we have more articles appearing about this.

The second possibility is one that virologists are loath to discuss openly but are definitely considering in private: that an Ebola virus could mutate to become transmissible through the air. You can now get Ebola only through direct contact with bodily fluids. But viruses like Ebola are notoriously sloppy in replicating, meaning the virus entering one person may be genetically different from the virus entering the next. The current Ebola virus’s hyper-evolution is unprecedented; there has been more human-to-human transmission in the past four months than most likely occurred in the last 500 to 1,000 years. Each new infection represents trillions of throws of the genetic dice.

If the New York Times is publishing this, somebody is worried.

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Maynard Brandsma

Tuesday, September 2nd, 2014

I was just thinking tonight about an amazing character I knew years ago. In 1972, I moved to Mission Viejo and began a surgical practice at Mission Hospital, now known as Mission Medical Center. When I arrived in December of 1972, I met an internist who had an amazing career and personal history. He was born in Holland and during World War II was supposedly a fighter pilot in the Dutch Air Force in what is now Indonesia. At the time it was the Dutch East Indies. He was also a physician at the time and was chief of staff at the hospital in Indonesia where another physician friend, Sergei Lockareff was born.

Maynard practiced as a physician in Santa Monica and was the personal physician for a number of movie stars, including Humphrey Bogart, Greer Garson and Carole Landis.

Life seemed very good indeed. But Bogie came home one day and told me that he’d run into an old co-star, Greer Garson.
Over lunch, she’d announced that she didn’t like the sound of his cough, and dragged him to see her doctor, Maynard Brandsma, at the Beverly Hills Clinic.

I was so used to Bogie’s cough that I never paid too much attention. He’d been off his food a little, but that wasn’t unusual. I should have realised at once that the mere fact that he’d consented to go with Greer to a doctor was indicative of something serious. Any time I’d ever mentioned a doctor to him, Bogie bristled.

Maynard discovered Bogart’s esophageal cancer and cared for him during that illness. Another physician friend, Burt Meyer, was the surgeon who operated on Bogart and who later said that the cancer was so small that he would never operate on another. If he couldn’t cure that one, there was none he could cure. Burt operated on John Wayne for his lung cancer with better luck.

Maynard was the physician who examined and treated the wife of David Niven for her fatal head injury, suffered when she fell down a flight of stairs in the dark at a Hollywood party.

When I came to Mission, Maynard had been there for several years. He had moved to Mission Viejo after marrying his second wife Mickie. He was active in practice and was kind of intimidating to a new surgeon. By that time, he was 65 years old but still very active. I remember that he tried to get me to join the Coto de Caza gun club, which was abruptly closed by the developer in 1991. At the time that Maynard was a member there was good quail shooting there but I couldn’t afford it.

He was quite the character. One night his telephone did not answer and the hospital asked the sheriffs to go to his house and let him know it was pout of order and they were trying to reach him. They knocked on his door at 3 AM and he came to the door with a .45 automatic held behind his back. Things were far less tense with the police in those days and they thought nothing of it.

The hospital was quite small at the time and Maynard was seeking a second career and life with his new wife. His career at St John’s Hospital in Santa Monica was spectacular in that he had been chief of staff and had a Hollywood practice, as well. One of his patients was John Ford and he made the diagnosis of Ford’s colon cancer that ultimately killed him.

Maynard was a good physician and continued to practice for a number of years after my arrival. Eventually, he and Mickie moved away and they are buried in Montana. He was a very colorful character and I remember him fondly.

Medicine is coming to be a government benefit.

Sunday, August 3rd, 2014

Obamacare is having serious trouble as I have discussed. The success stories, like California, are an example of what I have called Medicaid for All.

“It’s a total contradiction in terms to spend your public time castigating Medicaid as something that never should have been expanded for poor people and as a broken, problem-riddled system, and then turn around and complain about the length of time to enroll people,” said Sara Rosenbaum, a member of the Medicaid and CHIP Payment and Access Commission, which advises Congress.

Most of the new enrollees are Medicaid members and those enrolled in “private insurance” learn that they have severely restricted choice of doctor or hospital.

Now we have a new development.

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What next for health reform?

Saturday, July 26th, 2014

It looks to me that the Supreme Court will have little justification for continuing the Obamacare program as it exists. The Halbig decision should kill it off. It is clear that the IRS subsidies to federal exchange subscribers are illegal.

The only statement anyone has found in the legislative history that addresses this point comes from the Act’s lead author, who affirmed that Congress did intend to withhold tax credits in federal Exchanges. During a September 23, 2009, mark-up of his bill, which ultimately became the PPACA, Senate Finance Committee chairman Max Baucus (D-MT) refused to consider a Republican amendment regarding medical malpractice on the grounds it fell outside the Committee’s jurisdiction. Sen. John Ensign (R-NV) protested, asking how Baucus’ bill could do other things that lie outside the Committee’s jurisdiction, like direct states to create Exchanges. Baucus responded the bill creates tax credits, which are within its jurisdiction, and makes eligibility for those tax credits conditional on states creating Exchanges. Conditional necessarily means that Baucus intended to withhold tax credits in states that did not create their own Exchanges.

I just don’t see how the Court can ignore that history. The political left has been on a rant about Congressional intent since the decision was announced.

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An Update on Medical Reform

Monday, July 21st, 2014

Cash medical practice or, in the phrase favored by leftists critics, “Concierge Medicine,” seems to be growing.

Becker is shifting to a new style of practice, sometimes called concierge or retainer medicine. With the help of a company that has been helping physicians make such shifts for over 13 years, he will cease caring for a total of 2,500 patients and instead cut back to about 600. These patients will pay an annual fee of $1,650. In exchange, they will receive a two-hour annual visit with a complete physical exam, same-day appointments, 24-hour physician phone access, and personalized, web-based resources to promote wellness.

The article suggest that all these doctors choosing to drop insurance and Medicare are primary care. Many are but I know orthopedists and even general surgeons who are dropping all insurance.

The concierge model of practice is growing, and it is estimated that more than 4,000 U.S. physicians have adopted some variation of it. Most are general internists, with family practitioners second. It is attractive to physicians because they are relieved of much of the pressure to move patients through quickly, and they can devote more time to prevention and wellness.

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New developments at the hospital where I used to practice.

Friday, June 27th, 2014

When I moved to Orange County in 1972, I joined a friend from my surgery residency in practice at a new hospital that had opened a year before. It was called “Mission Community Hospital,” and was owned by a group of doctors with one of the partners an owner of the new development of Mission Viejo. His name was Richard O’Neill and his family had developed Mission Viejo from part of their huge ranch.

The hospital was small with 110 beds total and the staff was made up of young doctors who had recently finished their training like me. The owners were mostly older doctors and practiced in another area of the county. Some of them we would not have allowed on the staff if they had applied. They largely left us alone and over a period of a few years we developed what we thought was the best hospital in Orange County.

Mission Hospital in 1975.

Mission Hospital in 1975.

This is what the hospital looked like in 1975. The swallows used to nest in that entry area. To the right of the entry, there was a doctors’ parking lot and, for a while, the hospital paid a kid to wash our cars. Tom and I always tipped him extra. The food in the doctors’ dining room was free and good and I got a bit pudgy. The hospital went to considerable trouble to make it friendly to doctors and we responded.

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Medicaid for all.

Thursday, June 5th, 2014

Obamacare has had its problems in implementation but the real problem is the fact that it has severely distorted the health care market by forcing people into narrow high cost markets that do not reflect the real situation in American health care. I have previously expressed my opinion on how to do health reform.

American health care has been distorted by the type of “insurance” that was brought into effect by employer-based insurance. That is prepaid care, not insurance as we know it in every other market.

The history of American health insurance is greatly distorted.

Now we have this latest iteration of the failure of the Obamacare method and the alternatives.

I have believed for some time that what we see is a system of Medicaid for all. The benefits are skewed by politics and the market mechanisms are crippled. Now we see the situation is even worse.

At least 2.9 million Americans who signed up for Medicaid coverage as part of the health care overhaul have not had their applications processed, with some paperwork sitting in queues since last fall, according to a 50-state survey by CQ Roll Call.

Those delays — due to technological snags with enrollment websites, bureaucratic tangles at state Medicaid programs and a surge of applicants — betray Barack Obama’s promise to expand access to health care for some of the nation’s most vulnerable citizens.

As a result, some low-income people are being prevented from accessing benefits they are legally entitled to receive. Those who face delays may instead put off doctors appointments and lose access to their medicines, complicating their medical conditions and increasing the eventual cost to U.S. taxpayers.

Democratic lawmakers who have promoted the law’s historic coverage expansion are wary of acknowledging problems that hand opponents of the Affordable Care Act another rhetorical weapon, said Robert Blendon, a professor at Harvard University School of Public Health and Kennedy School of Government.

What is going on ?

Meanwhile, Republicans usually eager to criticize the Obama administration or states for implementation problems risk looking hypocritical by showcasing the Medicaid waits. Many oppose expanding the program to people with incomes as high as 138 percent of the federal poverty line, as the law allows states to do, and are loath to demand more efficient enrollment to achieve that goal.

“It’s a total contradiction in terms to spend your public time castigating Medicaid as something that never should have been expanded for poor people and as a broken, problem-riddled system, and then turn around and complain about the length of time to enroll people,” said Sara Rosenbaum, a member of the Medicaid and CHIP Payment and Access Commission, which advises Congress.

Oh OK.

Updated numbers provided by Bataille indicate that the total number of people affected remains about the same as reflected in the document. About 1.2 million have discrepancies related to income; 505,000 have issues with immigration data and 461,000 have conflicts related to citizenship information.

Many years ago, I was still interested in health policy research. I had an office at UC, Irvine and Orange County, where I live, was undergoing a transition from fee-for-service Medicaid (MediCal in California) to a new HMO-based program called Cal OPTIMA. This seemed a good opportunity to study the outcomes in two contrasting systems for the same population. No studies had been done to see how the MediCal Population would repond to the different incentives of fee-for-service and HMO. I developed a proposal to study this transition at a time when databases for both systems were available. The data from the fee-for-service program was still current and the new HMO program would provide the opportunity to see how the MediCal patients fared under the new program. I had obtained the cooperation of the UCI statistics department and had had some experience with this sort of study at Dartmouth where I had recently compacted a Masters Degree program in health policy research.

The Orange County Health Department had hired the recent director of HCFA, the Medicare intermediary. Funding was available from a large endowment fund devoted to the study of low income California residents’ health care. The organization was called “The California Endowment” and was funded when Blue Cross became a for-profit entity and was obliged by the state to donate a large sum to charitable causes.

The proposal is here.

All that was needed was the approval of the Cal OPTIMA program to use their data. All the funding was assured.

They refused. I wonder why ?

Medicine and Evolution.

Friday, February 7th, 2014

A Final Word: I went by that site today to see what additional comments might have been posted after I left. Here is what remained:

I was referring to your claiming that people were being dishonest in their claims not to be YECs. It’s not that you disagreed with the values expressed by their self-identification, it’s that you didn’t accept that they were who they claimed they were. This makes productive conversation much more challenging.

Does that make sense?

I didn’t claim that people were secret YEC members. I commented that I was astounded at the vehemence of people who described themselves as “non-creationist Christians,” at attacking a person who supports and thinks evolution will be important in medicine in the next 50 years. Read some of the comments in italics below to see if I am overstating this.

I am very concerned, after this, at the role of Fundamentalist Christians in the GOP. They are far less tolerant of other opinion and resemble the global warming alarmists in the unwillingness to allow dissent.

Update #4: I am saving some of the material from the thread to remember what Ricochet is like.

The pseudo sympathy: Mike, frankly, you never had them straight in the first place. The entire thread, you thought you were fending off attacks from a group of Young Earth Creationists, but there was only one YEC among them. The rest of them were believers in one form of evolution of another, and just upset with your attitude.

Attitude !

Do you bear any of the blame for making this thread so unpleasant? I’m perfectly willing to have a discussion with you, and I’m semi-sympathetic to your viewpoint. I’m definitely not a YEC. But I can’t understand why you are being so flippant.
Flippancy is the problem !

No, you’re not. You might try reading the thread. I’ve been listing all the insults over on my own blog as a study of how this happens.

“Mike, I am personally not a young-earth creationist, but I think you are confusing two concepts here. ”

I’m always the one confused. Explained by the Ivy League.

This: “Or would he create a universe that showed millions of millennia of age, even though it was only seconds old?”

Led to this: “It’s nice that you all believe this. Good luck. Let’s hope your doctor doesn’t.”

Now that was my mortal sin to the crowd here. From that the following resulted:

“You are very flippant in dismal of my case for faith. Once again I have no problem believing that someone who believes that God put together the world in 6 days .”can also understand the significance of mitochondria. ”

I doubt that. Instead: “I have a far greater trust of a doctor who believes in God and lives it in his own life rather than one who is merely technically competent and sees the universe, and my life, as a happenstance of evolutionary doctrine.”

Now, the folks who are denying this is about creationism and is about my “attitude” seem to ignore those parts.

“Well that’s a glowing example of inability to actually argue the point. When you encounter indications that people disagree with your conflating micro and macro evolution, imply that anybody who doesn’t believe in the warm puddle or whatever the popular origin of life theory is this week is incompetent. ”

Now there’s a thoughtful statement.

” If I’m just an expression of evolutionary pressures, he might want to trim it up. (Has the advantage of being supported by all the various eugenics of recent history, including the ongoing slaughter of those unborn suspected of having genetic illnesses.)”

So now abortion has been dragged into it.

“You slander many very good doctors with your dismissive remarks.”

And I’m the problem.

“But what followed was a long-winded series of examples that do not make a case that any student of what evolution teaches must believe any of the paleo-biology tall tales about the long long ago history of this and that.”

More friendly repartee.

“In my opinion, the whole argument is silly. Humans simply don’t have the intellectual capacity to comprehend the creation. It’s like a dog trying to understand how a television works;”

More brilliance. My tolerance for this is less than yours or you didn’t read it.

“Mike has argued that we should (or, at least, he would) place professional barriers before those who disagree with his creation myths ”

Another mis-statement of what I wrote. I only mentioned my own letter writing which was not a barrier the last time I checked admission requirements.

“You are the one who said that you would keep Creationists out of med school.”

More mis-statement.

“Believing that the paleo- fields have very badly miscalculated the age of the earth has nothing at all to do with the ability of a doctor to conduct medicine. ”

I guess you agree. I don’t.

I then gave up. This colony of creationists, even those who deny they are “YEC,” wore me out.

UPDATE #3: The attacks continue and it has been several days !

I am also a Christian who doesn’t hold to a YEC point of view. (I would also add, although I hate to flaunt credentials, that I am a more recently trained physician than you, Ivy-League-trained, and hold a faculty position at a medical center that’s a bit fancier than yours.)

So there ! I have decided that I am a Libertarian and not a conservative, if that is what this is about.

UPDATE #2 The pushback has finally succeeded in making me a villain.

(Yes, I know the things I cited don’t make him right about YEC, necessarily. My point is that he’s been successful despite Mike K insisting that people like him should be prevented from being doctors.) ·

This followed a long list of accomplishments by a supposed acquaintance who had had a successful career as, as best I can tell, a pediatrician. This all began with my comment that, aside from not being willing to recommend a student who did not believe in evolution for medical school, I was neutral. I think I am no longer neutral. The “Young Earth Creationist” community seems to have a determination to oppose any evolutionary thinking by anyone. They also seem to have an very convoluted way of explaining why obvious facts are not as they appear.

UPDATE: The pushback from creationists surprised me a bit. I guess it shouldn’t have. I expected “We will just have to agree to disagree” sort of thing. Instead I got an interesting series of attacks on me.

Is it impossible for the Creator to have built all the evidences of age into His new creation? The reality of natural selection isn’t necessarily required to have a long and indefinite period of activity to apply today.

and

Well that’s a glowing example of inability to actually argue the point. When you encounter indications that people disagree with your conflating micro and macro evolution, imply that anybody who doesn’t believe in the warm puddle or whatever the popular origin of life theory is this week is incompetent.

and

There are plenty of good Christian doctors and biologists who are well-versed in cell biology and in how mutations happen and in natural selection processes that affect microbes and higher organisms.

This all reminds me of the epicycles, which were used to explain why Ptolmeic astronomy could not explain certain phenomena like the movement of planets. It took Kepler’s discovery of the elliptical orbits to resolve the matter finally.

The creationists seem determined to ignore the implications of molecular biology about evolution and maintain “Young Earth Creation” in the face of the evidence of ancient biology.

But what followed was a long-winded series of examples that do not make a case that any student of what evolution teaches must believe any of the paleo-biology tall tales about the long long ago history of this and that.

Even Copernicus wanted to learn why the planets did not follow the rules of Ptolmeic astronomy. Today, that is considered rude. I may have to reevaluate my opinion of creationists. I have considered them harmless ill educated religious fundamentalists. They are far more aggressive than I had believed in attacking any disagreement.

I accidentally got into a debate about evolution at another site today. I didn’t want to get into this as I know there are many people, many of whom share my political affiliation, who are adamant about creationism, as the left often refers to it. Still, I have posted my opinions here in the past. I think molecular medicine is going to become even more important in the future and I do not understand how a physician can understand molecular medicine without molecular biology. There are many examples of evolution that must be understood to appreciate certain areas of medicine.

I think a physician can practice as a GP and not believe in evolution. I know a few. They are not likely to understand the future of medicine but they are my age and will not be practicing for long, if they are not yet retired.

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More Obamacare news

Saturday, January 18th, 2014

UPDATE: More News.

This is supposed to be reassuring.

Obamacare contains a $25 billion federal risk fund set up to benefit health insurance companies selling coverage on the state and federal health insurance exchanges as well as in the small group (less than 50 workers) market. The fund lasts only three years: 2014, 2015, and 2016.

The government’s risk management program for the insurers has three parts (the “3Rs”):
A revenue neutral Risk Adjustment System designed to level adverse claim costs between health plans.
A Reinsurance Program that caps big claim costs for insurers (individual plans only).
A Risk Corridor Program that limits overall losses for insurers.
Of the $25 billion, $20 billion is earmarked for the Reinsurance Program and $5 billion goes to the U.S. treasury.

First, the Reinsurance Program caps big individual claim costs for insurers––in 2014, 80% of individual costs between $45,000 and $250,000 are paid by the government, for example.

Then comes the Risk Corridor program. Participating health plans will receive payments from the federal government in any of the following circumstances:
The plan’s costs for any benefit year are more than 103% but not more than 108% of the health plan’s targeted amount. The feds will reimburse 50% of all costs in excess of 103% of the medical cost target.
If the plan’s costs are more than 108% of the annual target, the feds will first pay the health plan a flat 2.5% of the target and then reimburse the plan for 80% of their claim costs above the targeted amount––with no upside limit.
Target cost is simply defined in the new law as a health plan’s “total premiums (including any subsidies) reduced by the administrative costs of the plan.” It is whatever the health plan projected its premium needed to be to pay medical costs.

The CMS has a new contractor for Obamacare, not just the web site. The previous contractor, CGI Federal, has been replaced rather suddenly.

“Accenture, one of the world’s largest consulting firms, has extensive experience with computer systems on the state level and built California’s large new health-insurance exchange. But it has not done substantial work on any Health and Human Services Department program.
“The administration’s decision to end the contract with CGI reflects lingering unease over the performance of HealthCare.gov even as officials have touted recent improvements and the rising numbers of Americans who have used the marketplace to sign up for health coverage that took effect Jan. 1.”

CGI Federal is the company connected with Michelle Obama through her classmate, a fellow Princeton alumna.

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