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Friday, October 24, 2014

What I learned from Ebola

I’m sitting at my dining room table trying to reflect on and process the events of what, without a doubt, will go down in the annals of infection prevention as a pivotal point in time. Hospitals across the country furiously raced to prepare for Ebola, propelled by the unfortunate news of transmission of the virus to 2 nurses at Texas Presbyterian Hospital in Dallas. I’ll share with you what I think are the lessons of this incredibly interesting week:

Texas Presbyterian Hospital isn’t the exception, it’s the rule. It’s easy to be the Monday morning quarterback and criticize the emergency medicine providers for initially missing the diagnosis of Ebola, but given that this was the first case to ever present to an emergency department in the U.S., it should not be surprising. In the process of diagnosis physicians are trained to use probability in their reasoning. And Ebola simply wasn’t on their radar screens.

It’s also important to keep in mind that even today given everything we know, fever in a returning traveler from Liberia is most likely not caused by Ebola virus disease. Malaria remains a much more common diagnosis. For this reason, our Ebola plan reminds physicians to consider infectious diseases consultation in the setting of a person under investigation for Ebola, so as to avoid having a patient die of falciparum malaria while Ebola is being ruled out.

In addition, there may have been, and likely were, systems issues at play. There are many distractions in the hectic environment of an emergency department that may have had impact as the physician worked through Thomas Duncan’s case. Nosocomial transmission to healthcare workers would have also likely happened at almost any hospital with the exception of the four hospitals that have a biocontainment unit. While American hospitals have made great strides in reducing health care associated infections over the last decade, the challenges posed by Ebola virus in terms of the prevention of transmission are unparalleled.

The efficacy and effectiveness of personal protective equipment (PPE) need to be considered. By efficacy we mean how well PPE works in the ideal setting to protect the healthcare worker. Effectiveness is how well it works in the real world. For most pathogens, this difference is likely quite small. Not so for Ebola. Removing PPE in the Ebola setting without contaminating yourself is a Herculean effort, and we are dealing with what Dick Wenzel calls “an unforgiving virus.“ Before Ebola, the implications of minor errors in doffing were trivial. Now they’re life-threatening. An article in today’s New York Times sums it up beautifully:

Debra Sharpe, a Birmingham, Ala., biosafety expert, has overseen safety at a nonprofit laboratory that researches emerging diseases and bioweapons, and has run a company that trained workers to handle biological agents ... “It’s totally shocking ... It would take me anywhere from 4 to 6 weeks to train an employee to work in a high containment lab in a safe manner. It’s ludicrous to expect doctors and nurses to figure that out with a day’s worth of training.

To her comments I would add that the challenging setting of an ICU with an Ebola patient having 10 liters of vomiting and diarrhea per day is nothing like the controlled environment of a specialized laboratory dealing with contained aliquots of the virus. How well PPE works in the lab approximates efficacy. How well it works in the ICU is a measure of effectiveness.

The most advanced ICU in the best U.S. hospital is not a biocontainment unit. It’s absurd to think that the standards of a biocontainment unit can be met outside of that special setting. These units have special physical layouts with lab facilities, specimen dip tanks, employee showers, and autoclaves. They were created and supported with federal funding, and their providers have had ongoing training over years. So we need to realistically attempt to match the facility with the expected function: all hospitals should be proficient at rapidly identifying a potential Ebola patient, quickly isolating them and providing initial care, but once the diagnosis is confirmed, these patients should be transferred to a specialized biocontainment unit if a bed is available.

We need to think about exposures differently. In infection prevention, we tend to classify exposures to infectious agents on the basis of whether the exposure was protected: Did the nurse have on an N95 mask when she treated the patient with tuberculosis? Did the young man wear a condom when he had sex last night with an HIV-infected man? Typically, unprotected exposures pose greater risk of infection than protected exposures. In Dallas, the same paradigm was applied: the unprotected healthcare workers in the ER who evaluated Mr. Duncan before he was suspected to have Ebola were thought to be at higher risk than those who cared for him in the ICU will full PPE. This turned out to be wrong. Early in the course of Ebola the infectivity is low, as demonstrated by the fact that none of Mr. Duncan’s unprotected household contacts became infected. Late in disease, infectivity is very high and two nurses in gowns, gloves and face protection became infected.

Equipment and supplies for state-of-the-art care are inadequate. Several of us tried to find a stethoscope without ear tubes so that auscultation could be performed without bringing a device close to your face. We had no success. Much has been made of the fact that the Dallas nurses used PPE that didn’t cover their necks. This was even noted in an editorial in the New York Times. However, almost all (if not all) products that provide neck coverage, including bunny suits, are difficult to doff, making self contamination likely. Fortunately, our hospital has an in-house seamstress who rose to the occasion and rapidly began designing an item to cover the neck that is easy to remove. In addition, the supply chain for PPE is tenuous. Already, many items are on allocation and the national supply for some is not robust. Just-in-time manufacturing processes are not advantageous in the current situation.

Investment in infection prevention infrastructure and research is necessary. The health care system in the U.S. has talked a good game regarding the importance of infection prevention, but if budgets are statements of what we value, infection prevention has been a stepchild. Ebola should be our wake up call. Funding is needed to answer basic questions of infection control and to train hospital epidemiologists. Mandates for all hospitals to have infectious disease trained hospital epidemiologists should be considered. New models for compensation of infectious diseases physicians must be developed to encourage young physicians to pursue training in our field.

It was a truly challenging week. But from an infection prevention standpoint, it was challenging in a really good way. It allowed us to collaborate with experts across the health system and think creatively with them, while providing us an opportunity to demonstrate the value we add. I am very lucky to work with an amazing group of epidemiologists and a strong leadership team at the University of Iowa. And the Society for Healthcare Epidemiology of America (SHEA) staff did an outstanding job of promoting what we do in the mainstream media.

Lastly, we must keep all of this in perspective. Every issue I have talked about in this post is a first world problem. The tragedy of what is happening in West Africa remains incomprehensible.

Michael B. Edmond, MD, FACP, is the Chief Quality Officer at the University of Iowa Hospitals and Clinics. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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The 'nocebo effect,' statins, and Dr. Ben Goldacre

I just recently became aware of a study that came out in March of this year which concluded that statins, drugs like Lipitor (atorvastatin) and Zocor (simvastatin), which people take, increasingly, to lower their cholesterol and their risk of heart disease, have NO SIDE EFFECTS. Here is a paper which explains the study. It is not possible to link to the actual study in the European Journal of Preventive Cardiology because they want me to pay for it.

The paper says that, when comparing patients who took statins to ones who took an inactive pill, the side effects of both were about the same. That is called the “nocebo effect.” Many people have heard about the “placebo effect” in which a sham treatment or sugar pill has a beneficial effect due, we think, to the fact that the subjects who receive it think it will work. Placebo, in Latin, means “I will please” and nocebo means “I will harm.” So the researchers who wrote the paper about statins, after reviewing the data, found that patients who believed they would have side effects on statins did have side effects, whether or not they took the real drug. This is the nocebo effect. It implies that statins have no more side effects than sugar pills.

Now this would be really interesting if it were true. But it’s not, so it’s just really annoying. Patients who have received these drugs and physicians who prescribe them have noticed such a marked incidence of side effects, especially muscle weakness and pain, which resolve when the medicine is stopped, that any study questioning that finding is extremely suspect. When I heard about the article, I looked a bit further to see who had written it and what data they had looked at. I suspected that the study had been funded by pharmaceutical company lackeys using faulty data. It turns out I was only half right.

One of the major authors on the paper is a British physician named Ben Goldacre who is absolutely passionate about revealing the truth in scientific research and medicine, particularly in research done by unscrupulous pharmaceutical companies. He has founded a group, AllTrials, to promote honesty in reporting the results of clinical trials of medications. He actively publishes articles aimed at lay audiences about ways in which drug companies use skewed data to mislead the public about the safety and effectiveness of their drugs. He has written a book, Bad Pharma, about how the pharmaceutical industry distorts the truth to get patients to use their products. He is passionate about it and appears to be an excellent human being.

So what happened? Why did this guy who seems to be such a voice for truth write this paper? He explains it all quite entertainingly and in much more detail than I will here in his column “Bad Science.” What happened is that he used very incomplete data about side effects from studies that were mostly performed and designed with drug company support to show that statins were safe and effective. They didn’t even ask about many of the side effects that patients frequently complain about and they didn’t evaluate for muscle weakness in patients unless their muscle enzymes were 10 times normal or more, which is extremely rare. Dr. Goldacre attempted to write a disclaimer to the effect that he believed his data was inadequate, but the paper had gone to press. Oops. The news that statins have no side effects was on front pages of newspapers. There must have been champagne opened in the spacious offices of the companies that produce these medications.

So we still need good unbiased data on the true side effects of statins, and that will be pretty difficult to get at this date. Statins are so commonly used that finding a cohort of patients who have never used them to participate in a double blind study to evaluate their short and long term side effects will be tough. There are several statins on the market, with different incidence of side effects based on their chemistry, and each would need to be tested. Different categories of patients have different side effects, and the side effects vary based on dosage. Most patients who are willing to take statins are already on them, since physicians love to prescribe them. Patients who don’t want to take them probably also don’t want to take them in a double blind fashion for a long period of time. We will probably have to settle for a re-examination of data which was collected but not released, if anyone has the time or energy to find and scrutinize that.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Thursday, October 23, 2014

Ebola: The questions keep coming

The progression of the Ebola epidemic, particularly the recent episodes of transmission to health care workers who wore appropriate personal protective equipment, raises interesting questions. Certainly we need to continue to work on learning everything we can about the best approach to personal protective equipment and minimizing the risk of transmission during the process of care. But it’s also time to rethink some of the rituals surrounding care that have persisted in hospitals for decades.

Academic medical centers by their very nature increase the number of interactions with patients. Trainees at all levels need to interview and examine patients, and participate in their care to acquire necessary skills. While the benefits to the trainee are obvious, in some cases the patients benefit as well, via the therapeutic effects of another empathetic ear or the uncovering of a critical clue by the careful history of a novice interviewer. However, with a disease like Ebola, which can be transmitted in the health care setting, has no post-exposure prophylaxis, no effective treatment, and a high mortality rate, a strict approach to limiting the number of individuals in the physical proximity of the infected patient is appropriate as recommended by CDC.

Limiting contact typically means that in addition to students, other trainees such as residents and fellows also do not enter the room. But perhaps this needs to be taken a step further. Perhaps there should be one “examining” physician whose documented exam is used by consultants in their evaluations so as to limit room entry. In many cases, an additional exam probably doesn’t add much value, and is often performed because it’s expected or to maximize billing. Even before Ebola, as hospital epidemiologists we’ve asked ourselves the simple question: does every person on the care team need to examine every patient every day? Every encounter adds some level of risk for transmitting pathogens in the health care setting, but with Ebola the implications of transmission are taken to a whole new level. Fortunately, given technologies such as Skype, the ability to interview patients should not be impacted.

Ebola also pushes us to reconsider therapies that have a reasonably high probability of futility but increase risk to health care workers. In the case of the Dallas patient, who underwent endotracheal intubation and hemodialysis, we are left to question whether these procedures played some role in infection of the critical care nurse. Should CPR, which would seem to involve a very high degree of risk to bedside providers, not be performed? The ethical issues associated with withholding these procedures typically associated with “routine” critical care need to be explored since the risk-benefit calculus is markedly shifted by the level of risk to health care workers.

Lastly, should health care workers be compelled to work with Ebola infected patients? Do they have the right to opt out? Should those who volunteer receive hazard duty pay? Should there be a compensation fund for families in the event a health care worker contracts Ebola disease occupationally and dies? How do we handle the issue of pregnant health care workers? In the long run, how do we design the hospital of the future to maximize safety of the patient and provider?

These initial questions demonstrate that the Ebola crisis is challenging us in many ways and will likely continue to do so for quite some time. But perhaps we’ll emerge from this with a more thoughtful approach to patient care that improves safety without sacrificing quality.

Michael B. Edmond, MD, FACP, is the Chief Quality Officer at the University of Iowa Hospitals and Clinics. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Which medical specialty should medical students choose?

A medical student recently asked my advice on her decision to pursue a career in dermatology. It was about 25 years ago when my own parents encouraged me to pursue this specialty. What was their deal? Perhaps, they anticipated future developments in the field and were hoping for free Botox treatments? As readers know, I rejected the rarefied world of pustules and itchy skin rashes for the glamor of hemorrhoids, diarrhea and vomit.

My parents were making a lifestyle recommendation. Dermatologists are doctors who sleep through the night. Spying one in a hospital is a rarer sighting than spotting a liberal Democrat at a Michelle Bachmann rally (unless a planted heckler). Nocturnal acne medical emergencies are uncommon. And anyone who has had cosmetic work done understands painfully that this is a cash business.

Here’s where some readers or dermophiles will accuse me of skin envy. Not true. Some dermatologists may be a tad thin-skinned over this assertion, but facts are facts. These docs have a soft lifestyle and earn much more money than most physicians do. Sure, these guys and gals see some serious stuff, but the nature of their specialty is less intense and frenetic than that of other colleagues.

Many professions push back when it is suggested that they are afforded unique and soft perks that most of us don’t have. Teachers, for example, never state out loud that having every federal holiday off, enjoying school vacations every few months and having 10 weeks off in the summer are unbelievable soft padding that no one else has. We know you work hard under difficult circumstances and we respect you and your profession. But just admit that you have some unbelievable professional cushions. This won’t diminish your self-worth or contributions to society.

Many medical interns and residents don’t consider lifestyle when they are making their career choice, and they should. Obstetrics is thrilling when you are 30 years old. Fifteen years later when you are overworked, tired and have your own kids, it may be slightly less thrilling to bring new life into this peaceful world in the middle of the night on a regular basis.

For me, leaving my own bed at an ungodly hour to haul out to the hospital is an unwelcome activity. I do not relish being awakened with phone calls or having to attend to an individual in the emergency room when the rest of Cleveland is soundly snoring. While gastroenterology is a more taxing specialty than the skin gig, it is still uncommon for me to have leave for the hospital during the black of night. Since we are in the era of medical hospitalists who are on staff around the clock, there is only a rare need for me to make a personal appearance. On most nights, my scope rests securely in its holster.

Do I think that medical students should consider lifestyle as they are contemplating their future? Absolutely. Indeed, the emerging culture of the medical profession has morphed from the prior culture when doctors worked 24/7 and interns were proudly on-call every other night. Medical doctors today are increasingly employed by institutions, work shifts and delegate the hassles of hospital life to hospitalists. Doctors are self-prescribing R & R.

Leisure, relaxation, avocations and personal time for reflection are not evil pursuits. They are the fuel that cultivates and sustains our humanity. Who wouldn’t welcome a little more humanity in the medical profession?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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