Sunday, February 21, 2010

Navy Investigates Murtha's Death - CNN's Elizabeth Cohen Reports Unhelpful Advice

Nine days after my post wondering if the late Rep. John Murtha's death after an elective gallbladder surgery was a result of a preventable medical error, CNN and the Washington Post report that the Navy is now opening an investigation.

"The review is being conducted to determine if Murtha died due to a preventable surgical error and whether any action against those who performed the surgery is potentially warranted." according to the CNN article.

While this is good news, what I found rather disappointing was CNN's senior medical correspondent Elizabeth Cohen thoughts on how Murtha might have acted differently to avoid this unforseen outcome.

"You really have to be an aware and empowered patient because in those two days it's likely that he likely felt something that he felt some discomfort or felt a bit ill and, of course, we aren't trying to blame the patient but if you feel anything at all strange following a surgery you have to go back to that surgeon."

While I suspect she is trying to be helpful, the advice she offers isn't particularly meaningful. Who doesn't feel a little discomfort, feel strange, or a bit ill after having surgery? What other past life experience provides a reference point on whether this post-operative recovery will turn out fine or be completely disastrous?

The reason she would say such a thing is because our healthcare system is not as good as it must be in preventing medical errors and eliminating missed opportunities for prevention and screenings. Patients don't want to constantly worry about being an "aware and empowered patient". They don't want to be burdened with the responsibility of being vigilant for bad outcomes. They would rather can focus on healing and getting better.

Our healthcare system must continue to focus on improving patient safety.

So, in the end, was Murtha's death preventable? While I don't have any specifics of his case, my sense is that unfortunately his death was the result of a known risk and surgical complication and not due to gross incompetence or negligence. Let's be frank the Navy's review of Murtha's death is only because of his status as a very visible Congressman. Had this occurred to someone else, I doubt a death after gallbladder surgery would have received this level of scrutiny.

If this review is done objectively, then I don't expect anyone to be reprimanded or fired.

His death, however, does serve as important reminder. Only have surgery if it is absolutely necessary.

Monday, February 8, 2010

Could Rep. John Murtha Have Died from a Medical Error or Omission?

While the news reports that Representative John Murtha of Pennsylvania died after complications from gallbladder surgery, the question no one is asking is whether his death was a preventable one or simply an unfortunate outcome. According to the Washington Post, Murtha had elective laproscopic gallbladder surgery performed at the Bethesda Naval Hospital and fell ill shortly afterwards from an infection related to his surgery.

He was hospitalized to Virginia Hospital Center in Arlington, Virginia, to treat the post-operative infection. His care was being monitored in the intensive care unit (ICU), a sign which suggests that not only was the infection becoming widespread but also that vital organ systems were shutting down.

Was his death preventable or simply unavoidable? One reference notes that when gallbladder surgery is performed electively that "the mortality rates are very low. (Even in the elderly, mortality rates are only 0.7 - 2%.)" Perhaps Murtha was one of the unlucky 2 out of 100 to have died from this elective surgery.

It is also equally likely that he died of a medical error or omission. As Dr. Atul Gawande notes in his newest book - The Checklist Manifesto - a simple list helped prevent less than optimal surgical outcomes. One item on the list is whether or not IV antibiotics were given at the time the surgeon begins the opening incision. You would think this would be obvious, yet in the operating room, there is a surgical team which as a group is responsible for the patient's care. Do they work as a highly functioning team? Are there clear lines of communications between the surgeon, anesthesiologist, nurses, and surgical techs? Sadly, communications are not as clear as they need to be. As Gawande notes, a simple two minute checklist not only forced communications (something as basic as an introduction to the surgical team - "Hi, I'm Dr. Gawande general surgeon") but also verified that critical tasks were completed. As a result, the checklist decreased the complication rates by 36 percent and death rate by half. Disappointingly only 20 percent of American hospitals have adopted these types of checklists.

The Leapfrog Group rates hospitals on their processes to keep patients safe. Bethesda Naval Hospital being a government institution isn't listed and is not part of the survey. (Leapfrog Group was founded by large employers, who purchase health insurance, to evaluate the care their employees receive from hospitals).

Virginia Hospital Center, where Murtha was hospitalized, didn't submit any information either even though it is listed in the Leapfrog Group database. Specifically, Virginia Hospital Center declined to respond to the survey on how they are doing to keep medical errors from occurring. Questions include whether there is adequate ICU staffing, processes to reduce ICU infections, and steps to prevent harm. Gawande notes in his earlier New Yorker piece that even intensive care units errors of omission and missed opportunities happen which can be avoided with checklists.

In other words due to lack of transparent information, both hospitals are black boxes - Bethesda Naval Center because it is a government run hospital and Virginia Hospital Center because it didn't submit any data. There is a good chance that Murtha's death was possibly avoidable. This doesn't mean that doctors aren't working hard or trying to do their best. I believe that getting medical care must be as safe as it is humanly possible. Having witnessing near misses in medical care with my family and understanding what it takes to make patient safety as routine as other highly reliable organizations, I recognize that there is still much to do.

In the mean time, what does this mean for you? Surgery is never routine. If you need to have an operation, check out the hospital and how it rates to keep you safe at The Leapfrog Group. Not listed there? See if you can get surgery at a hospital that is recognized by Leapfrog.

Monday, February 1, 2010

Vitamins - Scientific Breakthrough or Marketing Hype? The Truth.

Some patients love their vitamins spending hundreds to thousands of dollars annually. At times, they will even forgo proven medical therapy. As more Americans go without health insurance coverage while others face higher office visits and copays, increasing number of patients are seeking alternative natural therapies instead of medical care. Are vitamins really the scientific breakthrough and secret that doctors refuse to recommend or are they simply marketing hype? As any medical school student will tell you, the correct answer to any question is: it depends.

For certain groups, pregnant women, patients with macular degeneration, and vegetarians, vitamins and minerals may be recommended as research finds them helpful. Prenatal vitamins have more folic acid which has been found to decrease the risk of neural tube defects in the fetus. Vegetarians may need to supplement their diet with vitamin B12, iron, and vitamin D, which are absent in their food choices.

Patients with history of gastric bypass should be on a multivitamin that contains iron and vitamin B12. The surgery, which is used to cause weight loss in morbidly obese patients, can bypass part of the digestive tract responsible for absorbing these nutrients.

Women of all ages should take calcium and vitamin D to improve bone density to decrease their future risk of osteoporosis. This means at least 1000 mg of Calcium daily and Vitamin D 800 to 1000 international units (IU) per day. Women over 50 should be taking 1500 mg of calcium day. A common misconception is that a multivitamin has enough calcium. It doesn't!A typical multivitamin has about 45 mg of calcium (a glass of milk is about 300 mg).

Aside from these individuals, the result of us with a balanced diet should get the right amount of vitamins and minerals. You don't need the large mega-dose vitamin packs found at your local warehouse store or nutritional shop. Not only are they expensive but also unproven.

If you still feel like you can't get through life without taking vitamins, then at least be aware of the following:

Limit the amount of fat soluable vitamins that you ingest, specifically vitamins A, D, E, and K. Unlike water soluable vitamins which excess amounts are excreted by the kidneys, fat soluable vitamins can build up levels in the body.

Vitamin A - toxic levels begin at ingesting more than 50,000 IU daily. Upper limit of tolerable intake (what is considered the upper limit of normal but still safe) is 10,000 IU. Recommended daily allowance is 3,000 IU.

Vitamin D - upper limit is 2,000 IU. The current daily allowance is 600 IU. A new recommendation is expected in May 2010 by the Food and Nutrition Board. Vitamin D is obtained by the skin via sunlight exposure. With people indoors more often than generations ago and possibly the increased use of sunscreen, doctors are seeing more cases of vitamin D deficiency. Your doctor may prescribe a weekly dosage of 50,000 IU weekly for 3 months to replace. Low levels of vitamin D can cause muscle pains, so if a constant problem, ask your doctor to check your levels. (Cod liver oil, incidentally, is rich in vitamin D and is probably why growing up in Canada I had a lot of it during the winter. Ick.)

Vitamin E - recommended dosage is 22.4 IU with the upper limit of tolerable intake no more than 1500 IU. Some research suggested that there was increased mortality for those individuals taking more than 400 IU per day. Because of its antioxidant properties, researchers thought taking more was better. It wasn't.

Vitamin K - found in green leafy vegetables, it is the only fat soluable vitamin where there is no defined upper limit for toxicity. Overdose of vitamin K is rare.

Am I against vitamins? Of course not. For some patients in fact they are recommended. What I am against is, however, having individuals spend their hard earned money for therapies that aren't proven. Note that the FDA, under current legislation since 1994, has no oversight over nutritional supplements.

This is why all vitamin package inserts have the following statement:

* These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

Want to live well? A better insurance policy than vitamins is to not smoke, perform regular physical activity, take in five servings of fruits and vegetables, and possibly drinking alcohol in moderation (as a doctor I can't recommend that, but if you drink already, it might be o). Researchers found individuals who did all four behaviors added 14 years to their lives. Why don't more of us these activities? They all take some effort. Swallowing vitamins are quicker and easier.

If I still haven't convinced you not to take unnecessary vitamins, then at least check with your doctor before stopping your medical therapies or adding supplements that can interfere with your treatment.

Finally, please avoid colon or total body cleanses. Sounds natural and healthy, but again aren't required. A product found at a large nutritional chain's special "anti-oxidant" formulation basically consists of fruits, vegetables, and fiber. You can do that yourself for a lot less and it probably tastes better too.


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