Medical Malpractice News and Views


Welcome to our blog where we discuss current issues in medicine and law. We welcome your comments.

State Medical Boards Continue To Fail The Public.

January 11, 2021

Every state has a medical board.  While there are some differences from state to state, they are all alike in that their primary job is to protect the public from bad doctors.  They have been failing at this job for many years and continue to fail today.  Although it is not alone, I am going to focus today on the Arizona Medical Board.  It is emblematic of boards across the country.

Is AZ Medical Board protecting doctors or patients? | | azfamily.com

The Arizona Medical Board describes its mission as “To protect public safety through the judicious licensing, regulation and education of all allopathic physicians.”  Allopathic physicians are M.D.’s.  There are similar boards for osteopaths, chiropractors, naturopaths and podiatrists.  All of them profess essentially the same mission of protecting public safety.  All of them have the same failings.

Generally, medical boards do a good job of evaluating brand new doctors and issuing licenses to them.  They also do a good job of requiring that doctors take courses intended to keep their skills up-to-date.  These courses are called CME for Continuing Medical Education.

We have now exhausted the areas in which the medical boards to a good job.

Perhaps the most important area of failure for state medical boards has to do with licensure.  While some are better at it than others, you can find repeated instances of doctors credibly accused of wrongdoing in one state just pulling up stakes and moving on to another state and getting licensed there.  Nothing like a nice, fresh start somewhere where no one knows about your past problems.

Sometimes this is the result of the new state failing to investigate the conduct of the doctor in her former state.  Sometimes this happens because the doctor cut a deal with the old state to leave quietly in return for the old state’s medical board not publicizing his wrongdoing.  Sometimes it is the doctor’s old hospital or practice that agrees to keep things quiet in return for the doctor leaving the state and not contesting the allegations of wrongdoing.  After all, who needs bad publicity?  Better to let this doctor go hurt people in another state than to see your name in the newspaper or on TV associated with physician misconduct.

Once a doctor has a license in a state, it is pretty hard to lose it, although there are some ways.  One good way is to be convicted of a crime.  The medical board can’t very well ignore that.  Another good way is to be discovered to have a drug or alcohol abuse problem.  Medical boards are very aggressive with these doctors.

What about other actions that endanger the public?  Allegations from the public of poor medical care?  Not much of a concern to the medical board.  Allegations of medical malpractice, even when proved in court?  Not so much either.  There are some doctors in Arizona who have been sued repeatedly for malpractice and who are still allowed to practice.  This is even more disturbing when you consider that very few instances of malpractice end up being the subject of a lawsuit.  Doctors who are sued frequently for malpractice have usually left behind a trail of damaged patients.

So why are these doctors allowed to continue to practice?  In addition to patient complaints of malpractice made directly to the board, all malpractice lawsuits are reported to the medical board.  They know who these people are and what they are doing.  The answer, in my experience, is twofold.  In the first place, the medical board is controlled by doctors.  They have a lot of sympathy for their fellow doctors.  They know how hard it is to be a doctor and how difficult it is to please all patients.  There is a sense of “There but for the grace of God go I,” which appears to affect their review of the conduct of other doctors.  There is no such sympathy for the injured patients.

The second reason bad doctors are allowed to continue to practice is that medicine is a lucrative profession.  Faced with the possible loss of position, prestige and income, doctors hire smart, experienced, capable counsel to represent them before the medical board.  These lawyers know the ins and outs of the medical board.  They know what plays well before the board.  They know how to go about finding expert witnesses to testify in front of the board about how what the doctor in question did was not malpractice or, if it was, was just a little thing which should not affect the doctor’s license.  These lawyers frequently send their clients off to take additional training about the area of malpractice so, when the hearing comes, they can show how proactive the doctor has been in correcting the problem.  “See what the doctor has done to improve herself?  She knows better now.  You can be assured this won’t happen again.”

Surely, there is a better way to protect the public from malpracticing doctors.  The Arizona Medical Board has shown it is not up to the task.

Posted in Arizona Medical Board, Doctors, Hospitals, Lawsuits, medical errors, medical ethics, Medical Malpractice, medical malpractice lawsuits, medical malpractice lawyers, medical mistakes, Medical Negligence, Secrecy |

Hospital Pricing Is Broken.

January 04, 2021

A recent study by the RAND Corporation discovered that hospitals across the United States charge private health insurers far more than they charge Medicare for the same services.  The amount by which hospital bills exceed what they are paid by Medicare varies widely by location but one fact is consistent:  prices are highest where there has been hospital consolidation.

Telehealth helps one hospital reduce ER overflow hours from 1,700 to 148 |  Healthcare IT News

The basis of our economic system is the free market.  Goods and services, and hospitals offer both goods and services, are bargained for in the marketplace.  Good products and services are more highly sought after and can command a higher price.  Bad products and services have to charge less.  Sometimes, even with lower prices, they cannot find a buyer and are pushed out of the market.  The consumer is rewarded with good products and services at fair prices.  The free market no longer works when it comes to hospital prices.

There is a lot wrong with our health care delivery system.  We spend more money per person on health care than any other country in the world and yet our outcomes are well down the list of the best countries.  Not only do we get so little for our money, we don’t even provide health care to all our citizens.  By virtue of a historical accident during and soon after WWII, we developed a system in which health insurance was provided by employers.  No job, no health insurance.  As health care has become more expensive, many employers have either dropped health insurance as a benefit or required employees to bear a greater share of the costs.  So now, even among people who have jobs, many don’t have health insurance.

The high cost of health care is creating an unsustainable burden on our system of employer-provided health insurance.  The high cost of hospital care is a main driver of the ever-increasing cost of health care.  Why is hospital care so expensive?  Why doesn’t the free market deliver us good care at reasonable prices?

There are two main reasons the system is broken.  The first is the pattern of consolidation among hospitals.  In Arizona, our largest employer is Banner Health.  It also operates about half of the hospitals in the state.  The ones that are not Banner hospitals are usually operated by some other system that has multiple hospitals.  The more consolidation that takes place, the fewer hospital competitors there are in the market.  Basic economic theory applies here.  The fewer competitors in the marketplace, the less competition and less competition means prices will be higher.  The RAND study, and every other study of the subject, has found that the more hospital consolidation there is in a given market, the higher are the prices charged by hospitals there.

Health insurers that negotiate with hospital chains find them less willing to negotiate prices.  They can and do adopt a “take it or leave it” approach.  If there is nowhere else the health insurer can send its insureds for hospital care, it has no leverage and must accept whatever rates the hospital chain wants to charge.

The second main reason the system is broken is secrecy.  For a free market to function, buyers must be able to compare prices.  If a buyer does not know what sellers are charging for a particular product, there is no way the buyer can choose the best price.  Hospitals, and especially hospital chains, treat their negotiations with health insurers as trade secrets.  Once a deal is reached between a health insurer and a hospital, the hospital insists that the deal be kept confidential.  Health insurers do not know what prices are available in the market and, therefore, cannot choose the best option.  They are forced to negotiate in the dark.

Medicare, on the other hand, is the elephant in the room.  Given the number of people covered by Medicare, even large hospital chains cannot afford to refuse Medicare patients.  They are too large a portion of the population.  Medicare studies the cost of hospital goods and services and sets what it considers to be a fair price.  Now the shoe is on the other foot and the hospital must take what Medicare offers or refuse Medicare patients.  Of course, hospitals claim that the prices set by Medicare are too low and explain that is why they charge private health insurers so much more.

The inability of private health insurers to get anywhere near the deal Medicare gets is creating pressure for some sort of change in the way we as a society deliver and price health care.  Some proposed changes are relatively minor.  Other changes are more radical.  “Medicare for All” is an example of the far end of the spectrum.  However it happens, the current system is broken and unsustainable and has to change.  It will be up to Congress to pass legislation to force change.  Legislation, of course, means lobbying and the hospital chains are very effective at it.  Hopefully, good change is coming.

Posted in health, Health Care Costs, Health Insurers, Hospitals, Medical Costs, Medicare, Secrecy |

The Electronic Medical Record.

December 28, 2020

One of the requirements of federal law is that hospital records be recorded electronically.  The requirement for electronic medical records (“EMR”) has a number of justifications, including portability.  Patients are entitled to have a copy of their medical records.  When the record was paper, that meant someone had to copy all the paper.  The patient had to pay for the time of the person copying the chart and for the cost of the copies.   A chart of almost any length could get quite expensive.  With electronic records, the patient, who asks for a copy, is given a computer disc onto which the records have been transferred.  It takes only a few minutes to make the disc and the cost, if any, is minimal.

Doctors Say Electronic Medical Record 'Gag Clauses' Need To Go | Here & Now

Another reason for mandating EMR’s is that, much like the patient copy, the records are now easily transferred from institution to institution.  When patients are transferred to a new hospital with a higher level of care, their chart can be put on a disc and sent in the ambulance or helicopter with them.

Other reasons offered for requiring EMR’s are cost savings, better communication, the ability of multiple practitioners to have access to the chart at the same time, ease of making entries, reduction in prescription errors, and reduction in adverse drug interactions (because the computer can flag the potential interactions).  With all these wonderful things going for them, I almost feel guilty complaining about EMR’s.

EMR’s make my job as an attorney for patients injured by medical malpractice more difficult.  They make the chart harder for me to read.  Because information can be entered with just a quick keystroke, more information gets entered than if the nurse or doctor had to enter the information by hand.  The EMR is much larger than a comparable paper chart would be.

One of the biggest failings of EMR’s, in my opinion, is that they pretty much force the person entering the information to choose from “drop down boxes.”  Nurses are the providers most often faced with this problem and it makes it more difficult for them to accurately convey the condition of the patient.  For example, when I review the EMR from an emergency room visit, I see the following, “The onset of the problem was ______.”  The nurse has to click a box over the blank space and a number of choices will drop down.  These choices are something like “slow,” “rapid,” “insidious,” or “progressive.”  The nurse must choose one of these to fill in the blank, even if there are far better ways to describe how the condition began.

EMR’s naturally assume a cookie cutter appearance.  The level of detail is limited by the imagination of the person who establishes the template that the nurses have to fill out for each visit.  Each visit appears very similar to every other visit.  If the person creating the template does not offer many choices to the nurses, they cannot do a good job charting.  And because one of the goals of the charting from the point of view of the person creating the template is to encourage easy and quick charting, the tendency is to offer few choices so as not to slow down the process.

Another problem for lawyers like me is that we are at the mercy of the hospital computer people.  With a paper chart, the chart is what the chart is, although there have always been a few loopholes.  With the EMR, the data is in the computer and the hospital and their computer people decide what I get when I request a copy of the patient’s chart.  For example, Hospital A may decide that hourly temperature checks, which are in the computer, need not be a part of the patient chart and does not include them when I ask for the chart.  Hospital B may decide to include hourly temperature checks but to exclude something else.  While I can see what they put in, I cannot know what they decided to leave out.  I may never see information which is critically important to my client’s case and may never know that it was in the computer all the time but never produced by the hospital.

There are a number of companies that produce templates for EMR’s.  Much like the old wars between videotape players, their systems are not compatible.  Things will be a lot better for everyone when hospitals settle on a single format for EMR’s.

The final problem for me is one of overwhelming quantity.  If the hourly temperature checks are included, they may appear in two or three different parts of the chart.  It is hard to find things because the record is cluttered with information I have seen ten times before in other places.  It is like trying to get a sip of water from a fire hose.  Written charts that would have fit in one three ring binder, now occupy three binders.  This may be good for the people that manufacture paper but not so hot for me.

Electronic Medical Records are here to stay but they can certainly be improved.  I am not holding my breath.  Nor should you.

Posted in Doctors, electronic medical records, Health Care Costs, Hospitals, Lawsuits, medical charts, Medical Costs, medical errors, Medical Malpractice, medical malpractice lawyers, medical mistakes, Medication Errors, Nurses, Prescription Errors |

Informed Consent.

December 21, 2020

The requirement for informed consent means that a doctor may not perform a procedure on you without first explaining the risks and benefits of the procedure and getting your approval to go forward.  Informed consent is a critical part of any procedure but, in my experience, it is most often done in a rush and without adequate explanation of the risks.

Informed Consent for COVID-19 Risks: Frequently Asked Questions | The Doctors Company

I frequently meet prospective clients who have suffered an injury during a procedure who tell me the doctor never mentioned their injury as a possible outcome of the procedure.  To the contrary, they usually tell me that the doctor hardly discussed risks at all and assured them this was a low risk procedure that was going to go smoothly.

As is reflected in the drawing above, there is always a written consent form.  It is usually mostly “boilerplate” that is presented to every patient.  It names the patient and the doctor performing the procedure “and his assistants.”  It states that the patient has had all risks fully explained.  It then specifically lists many bad things that can happen and says these are just a few examples of the risks that have been explained.  Finally it states that all of the patient’s questions have been answered and that the patient consents to the doctor and his assistants performing the procedure.  I am not sure I have ever seen a situation in which the actual events matched the pretend events set forth in the written informed consent.

The written consent form is often presented to the patient by nurses at the hospital or at the surgicenter, wherever the procedure is to be done.  It is often presented just before the procedure.  It is presented as though it is nothing more than a written confirmation that informed consent has already been obtained by the doctor.  The doctor is not usually present when the consent form is presented.  The patient is not encouraged to read the consent form or to ask questions.  Even if the patient has questions at this point, in the absence of the doctor, the nurses are not going to be able to answer them, nor should they.

Although the written consent form is usually different than the consent that was actually discussed with the doctor and given by the patient, it is a part of the patient’s medical record, bears the patient’s signature and is considered by juries to be the holy word of God.  Good luck in getting a jury to believe that no one told you about a possible risk when it is listed, along with many others, on the written consent form.  Good luck in getting a jury to believe that the doctor never really discussed the risks of the procedure when the written consent says she did and that all questions were answered.

Given the critical importance of informed consent, it is just wrong that it is treated so cavalierly by doctors.  Most doctors view informed consent as a nuisance.  In their view, it is just another box that must be checked before they can do the procedure and get paid.  They don’t take it seriously and do not engage in a meaningful discussion with their patient about the risks and benefits of the procedure.  They just want the patient to trust their good judgment and be assured that the doctor would not have recommended the procedure, if the risks were not clearly outweighed by the benefits.  Don’t let this happen to you.

Much to the consternation of some doctors, their patients now often do research on the internet before coming to see the doctor to discuss treatment options.  You should be one of these annoying patients.  Do not rely on the doctor to explain all of the risks and benefits of the potential treatments or how one treatment may be better for you than another.  Do your homework before you go see the doctor and be prepared to ask questions.  You may even want to write your questions down and also write down the doctor’s answers.  Any doctor who objects to having a knowledgeable patient or to answering patient questions, is probably not a doctor that you want performing procedures on you.

 

Posted in Doctors, Fee for Service, Hospitals, Informed Consent, medical ethics, Medical Malpractice, medical malpractice lawsuits, Nurses |

They Did WHAT To Me?

December 14, 2020

If you have ever been the victim of medical malpractice during a hospital stay, it is unlikely that the hospital or the doctors taking care of you told you about it.  On those occasions when they do, it is usually because what happened to you is so obvious that they can’t just ignore it or sweep it under the rug the way they usually do.

Secrets doctors don't want you to know

I have been representing people injured by medical negligence for many, many years now.  It is a rare case in which the hospital or doctor admits that they made a mistake that injured a patient.  It happens, but not very often and, when it does, it is more often the result of a doctor wanting to do the right thing by the patient than it is a hospital voluntarily admitting a mistake.  Sadly, even when the doctor admits to a mistake, the doctor’s insurance company may still aggressively try to prevent the patient from making a recovery or may try to keep down the amount of any recovery.  The doctor may want to do the right thing, but the doctor cannot control what the insurance company does.

What most often happens when there is malpractice that injures a patient is that no one says a word to the patient.  She or he may be left to guess whether something went wrong or whether they just got a bad result.  After all, there are no guarantees in medicine.  Sometimes, the hospital or the doctor suggests to the patient that what happened was just one of those things that no one could have anticipated or prevented.  Sometimes the doctors or the hospital flat out lie to the patient about what happened.

There are many reasons why doctors and hospitals refuse to own up to their mistakes, but the main one is our old friend: money.  Admitting a mistake is an invitation to the patient to make a claim.  Claims mean possible payouts.  Claims mean possible bad publicity.  Claims mean legal costs.  Hospitals are in it to make money.  While they have insurance, most are self-insured for at least the first couple of million dollars of any claim.  This means that for any successful claim on which the hospital has to pay, the money comes directly out of the hospital’s pocket.

Doctors, who have insurance, are not going to be paying claims out of their own pockets but successful claims may result in higher malpractice premiums on down the road.  Successful claims are also reported to the Medical Board, which may open an investigation.  A Medical Board investigation costs money and can result in discipline against the doctor, which can also cost money.  Successful malpractice claims may cause the hospital to restrict or refuse hospital privileges to the doctor.  If a doctor cannot admit her or his patients to the hospital or cannot perform surgery at the hospital, that can cause huge financial problems for the doctor.  Why invite all this by admitting to the patient that you made a mistake?

Another reason doctors and hospitals don’t tell patients they made a mistake is that they can get away with it.  If a patient figures out that they have been injured by malpractice and makes a claim, doctors and hospitals will deny that they did anything wrong.  If the case goes to trial, doctors and hospitals win 85% to 90% of the time, even when the evidence of malpractice is strong.  Juries just don’t want to believe that doctors and hospitals kill and injure patients.  Too hard to sleep at night, if you believe that.

There is no incentive to tell the patient the truth about what happened.  If the doctor and hospital deny any fault but the patient ultimately prevails, either by way of settlement or at trial, there is no adverse consequence for the doctor or hospital having first denied any responsibility.  It never hurts to deny your mistakes and to force the patient to try to prove their case.  Making it as hard a slog as possible also discourages the next patient from even trying.

Despite the vaunted ethics of the medical profession, if you are injured by medical malpractice while you are in the hospital, no one is likely going to come to your rescue and admit the truth.  Don’t believe everything you are told by the people taking care of you.  If you get a bad result, ask yourself whether you might be the victim of malpractice.  Ask the nurses.  In my experience, nurses are sometimes willing to spill the beans, as long as you promise not to quote them.  They see the cover ups and are often offended by them.  Get your medical records.  You are entitled to them.  See if you can figure out what happened.  Consider taking the records to an experienced medical malpractice lawyer for review.  Until human nature changes, you are on your own.  Good luck.

 

Posted in arizona certified medical malpractice lawyers, arizona certified personal injury lawyers, Arizona Medical Board, disclosure of medical mistakes, Doctors, Hospital Negligence, Hospitals, Lawsuits, medical charts, medical errors, medical ethics, Medical Malpractice, medical malpractice claims, Medical Negligence, medical negligence lawyers, Nurses, plaintiff, Secrecy |

How Much Longer Can Fee For Service Last?

December 07, 2020

I recently read a post by a representative of the American College of Cardiology which discussed the origin of the fee for service model and its pernicious effects on the delivery of health care in the United States.  Fee for service means that the health care provider bills for each service separately and is paid on the basis of the number of services provided.  Fee for service rewards quantity over quality.

Fee for Service Dentistry - A Complete Consumer Guide

The author of the post quite properly pointed out that the United States has the most advanced treatment options for cardiovascular disease in the world.  Cardiologists have been able to reduce mortality due to cardiovascular disease but this progress is threatened by the fee for service model.  We have the highest cost per capita for care in the world and the cost of care here is accelerating faster than anywhere else in the world.  Although we spend more per person on health care than anyone else, our measures of success overall are well behind many other industrialized nations.  Compared to the rest of the industrialized world, we are not getting our money’s worth.  This is unsustainable.

The fee for service model creates a conflict of interest for the health care provider.  It is in the best financial interest of the provider to decide you need a procedure or service..  It may not be in your best interest to receive the procedure or service.  The system should not be set up to give the provider a financial incentive to provide care you don’t need.

As it stands now, the more things a doctor does to or for you, the more money she or he makes.  It doesn’t really matter if you benefit from what the doctor does.  Some of the tests the doctor orders may not really be necessary, but the doctor gets paid for ordering them, interpreting them and reporting to you about what they mean, so you get the tests.  You may not need to have two surgeons in the room for your procedure, but since whoever is paying the bill will pay for two, you get two.  You may not need to have that mole removed, but since the dermatologist gets paid more if it comes off, the chances are increased that your mole will be removed.

What we need is a system that rewards good care and improved patient health.  The alternative to fee for service is a value based health care delivery system in which providers are paid on the basis of patient outcomes.  Providers are given incentives to help patients improve their health, reduce the incidence and effects of chronic disease, and live healthier lives.  We are moving, albeit slowly, to a value based model.  Under the Affordable Care Act, Medicare and Medicaid are rewarding hospitals on the basis of the care delivered to patients.  It is not yet clear whether these programs for hospitals are having their intended effects or not.

There are many different ways to reward providers for value rather than just for quantity.  Capitation is one such method.  Under the capitation model, a primary care physician is given a certain amount of money for each patient for a specific period of time.  If the patient can be kept healthy, the provider gets to keep whatever money was not spent providing care for the patient.  The physician has an incentive to make sure the patient, for example, takes her medicines, stops smoking, gets regular blood pressure checks and generally complies with the doctor’s orders.  The patient is healthier, hospitalizations are reduced, and the amount we as a society spend on health care is reduced.  A win-win.

Of course, doctors are human and zealous about guarding their rights and privileges.  Any changes that reduce physician income will be opposed by some doctors.  They won’t say they oppose the changes because they reduce their income.  They will argue that they oppose them because they will lead to “socialized medicine” or will in some way damage patient freedom of choice.

Changes to our bloated, inefficient health care delivery system will always be contentious.  We have to accept that fact and commit to pushing forward to improve the system regardless of the fact that some doctors oppose the changes.  We can and should be able to do at least as well in caring for our citizens as the other industrialized nations of the world.

 

Posted in Defensive Medicine, Doctors, Fee for Service, health, Health Care Costs, Health Insurers, healthy living, Hospitals, Medical Costs, medical ethics, Medicare, Rationing |

The Medtronic Insulin Pump Lawsuits Are Beginning.

November 30, 2020

If you read these posts with any regularity, you know my 10 year old grandson is a Type 1 diabetic.  He just “celebrated” his “diaversary,” marking 7 years since his diagnosis on the Labor Day weekend in 2013.  He manages his glucose levels with the help of an insulin pump manufactured by Medtronic.  There have been major problems with a recent updated version of the pump.

For those who may not be familiar with Type 1 diabetes (Type II is far more common), it is the result of an autoimmune process in which the body’s immune system attacks and destroys the insulin producing cells in the pancreas.  Insulin is the hormone that converts glucose (sugar) in the bloodstream into energy the body needs to operate.  If there is no or too little insulin in your bloodstream, your body cannot use the glucose to produce energy.  It must start cannibalizing body fat for energy and dumping excess glucose in the urine.  If not diagnosed and corrected, the process is fatal within a few months.

If you are in good health, your pancreas monitors your blood glucose levels and decides how much insulin you need to keep your blood sugar levels in the proper range.  Too much glucose in the blood is called hyperglycemia.  The more carbohydrates you consume, the more glucose you will have and the more insulin you need.  If your blood sugar levels fall too low (hypoglycemia), the pancreas will release glucose into the blood to raise the level into the appropriate range.  Too much glucose in the blood will cause damage over the long term, including blindness and nerve damage in the extremities.  Too little glucose causes immediate problems, which can include confusion, loss of consciousness and even death.  Type 1 diabetics always keep something with them to quickly raise blood sugar, in the event of a hypoglycemic event.  Keeping the blood glucose levels from going too high is important but not as critical as keeping them from going too low.

The insulin pump is a major development in the treatment of diabetes.  It delivers insulin into the bloodstream without the necessity for repeated injections.  At the present time, the patient must program the pump and tell it how much insulin to deliver.

As with most other things, it is almost impossible to replicate the fine balance our bodies have developed to deliver just the right amount of insulin.  No matter how careful a diabetic is in watching what she eats and calculating the proper dose of insulin to enter into the pump, it may not be enough or it may be too much.  The holy grail for insulin pumps is what is called the “artificial pancreas,” a closed loop system in which the system regularly checks glucose levels in the blood and orders the pump to deliver insulin or glucose to keep blood sugars in the appropriate range.  The technology already exists to do this but the FDA is concerned about the reliability of the system, which includes the reliability of the pump itself, and, until it is satisfied that all parts of the system are reliable, it will not authorize marketing and sale of the closed loop system.  This is where Medtronic’s current pump problems come in.

Medtronic is one of the major manufacturers of insulin pumps and sensors.  In 2016, Medtronic introduced the MiniMed, a hybrid closed loop system, after obtaining FDA approval.  The hybrid system monitors blood sugars every 5 minutes and directs the pump to either administer or withhold insulin.  However, the user must program the pump based on how many carbohydrates are eaten at mealtimes.

There turns out to have been a manufacturing/design defect in the MiniMed pump.  The pump has a reservoir, which holds the insulin and which must be changed out every week or so.  A retaining ring holds the reservoir in position.  There was a problem with the ring; it would break.  If it did, it allowed the reservoir to work its way loose.  This might result in either no or not enough insulin being delivered or, even worse, too much insulin being delivered.  When too much insulin is delivered, especially if this occurs at night when the diabetic is asleep, a profound hypoglycemia can result which can seriously injure or even kill the patient.

After the problem was discovered, Medtronic instituted a recall but some diabetics were injured, purportedly thousands, and there was at least one death related to the defect.  Over 300,000 pumps were recalled in a Class 1 recall.  This FDA classification is reserved for only the most serious recalls in which there is a risk of serious injury or death.  Now the lawsuits are beginning to be filed and law firms are looking for potential clients, who were injured by the defect.

Continued progress in pump technology is important.  For reasons that are not clear, more and more young people are being diagnosed with Type 1 diabetes.  The advent of a reliable, fully automated, closed loop system will save many lives and make the lives of all Type 1 diabetics easier.

Posted in General Health, health, healthy living, Medical Devices, science news, Type 1 Diabetes |

Hospital Infections

November 23, 2020

Hospitals are where the sick people are.  While patients may go home after they get better, they often leave bacteria and viruses behind, where they infect the next round of patients.  You may go to the hospital to get well, but you may end up getting an infection in the hospital that can leave you permanently disabled or can even kill you.

Bacterial Infections | Sepsis Alliance

Every hospital has protocols intended to reduce the risk of infection among its employees and its patients.  Even if these protocols are followed carefully and to the letter, and often they are not, infections persist.  It is a tall order to prevent infections in hospitals for a number of reasons.

Sick people come to hospitals.  Many of them bring with them the germs that made them sick in the first place.  They breathe those germs out when they talk or cough.  They leave germs on the surfaces they touch.  They deposit germs on the nurses or doctors who treat them and those nurses and doctors go on to see other patients.  By their very nature, hospitals are exposed to many different types of bacteria and viruses.

Even worse is the fact that some of those bacteria are resistant to antibiotics.  For many years, we have been giving antibiotics to animals to prevent disease.  We ingest these antibiotics when we eat chicken or beef.  We ask for and doctors give out antibiotics routinely.  Antibiotics have found their way into the water supplies as well as into the food supplies.  Combine these facts with the laws of nature and you have a recipe for disaster.

Bacteria are living creatures.  When exposed to an appropriate antibiotic, most of them will die.  The problem is that not all of them will die.  Over time, after repeated exposure to an antibiotic, some bacteria will develop a resistance to it.  Doctors will then switch to a different antibiotic and use it until the bacteria develop a resistance to it as well.  We are running out of antibiotics to switch over to.  There are now some very aggressive and potent bacteria that have developed resistance to all of our antibiotics.  If they are not already there, these bacteria will eventually be brought to hospitals, where they will be virtually impossible to destroy.

Hospitals are also problematic because so many of the people there are sick and their illnesses weaken their immune systems.  Bacteria and viruses they might be able to resist when they are healthy are now able to overcome their compromised immune systems.

Another problem at hospitals is the use of procedures which bypass the body’s primary defense against infection: the skin.  Our skin keeps bacteria out of our bloodstreams and away from our tissue.  In the hospital, however, we may have an procedure in which an incision is made in the skin or we may need a catheter or a ventilator.  Each of these presents an opportunity for bacteria to bypass the skin and enter the body.

If you are not going to the hospital for an emergency, you may have a choice about where to go.  Doctors who practice in hospitals usually have privileges at more than one hospital.  If you have the ability to choose your hospital or to at least make a suggestion about where you would like to go, visit Medicare’s Hospital Compare site.   It has lots of useful information about hospitals, including information about infection rates and how hospitals stack up against the national averages.

I also recommend you take a look at the information provided by the Centers for Disease Control about infections and what you can do as a patient to reduce the risk of a dangerous infection.  There is some very good advice to be found there.

As always, be aware that health care is a two-edged sword.  While it helps make us better, it exposes us to some risks.  Do your part to keep from spreading infections to others and to keep others from infecting you.

Posted in antibiotic resistant bacteria, blood infections, Doctors, General Health, health, healthy living, Hospital Negligence, Hospitals, Infection, Medicare, Nurses, Sepsis |

Urgent Care or Emergency Department?

November 16, 2020

One of the most obvious changes in the medical landscape over the last 15 years has been the proliferation of urgent care clinics.  You can’t drive down almost any street in a major metropolitan area without passing at least a couple of urgent care centers.  These centers have become common because many people do not have health insurance or do not have a primary care physician.  When they get sick, they need somewhere to go.  Urgent care centers offer convenience and, in today’s world, convenience sells.

How Urgent Care Centers are Changing the Health Care Delivery Landscape

When you become sick or injure yourself and decide to seek medical care, you have to make a decision.  Assuming you are going to seek immediate treatment, you need to decide whether to go to an urgent care center or to a hospital emergency department.  There is a big difference between the two and the choice can be important, almost to the point of being life saving.

Hospital emergency departments are usually staffed by doctors who have extensive training in emergency medicine.  They have available to them the resources of the hospital, which include the ability to perform complex lab tests and radiology studies, such as CT and MRI.  If your condition is serious enough, they have the ability to arrange for you to be admitted to the hospital.

Urgent care centers are not usually staffed with residency trained emergency medicine physicians.  Over the course of my practice, in the cases I have brought, the doctors have often been family practice doctors.  The urgent care center may have an x-ray machine but it won’t be able to administer a CT or an MRI.  It is not likely to be able to do all of the lab tests a hospital emergency department can arrange.

If your condition is a serious one, you want to go to the emergency department.  If your condition does not appear to you to be serious but one you want evaluated and for which you want some treatment, the urgent care center will probably be just fine.  Chest pain, head for the ER.  Stroke-like symptoms, head for the ER.  Just feeling poorly with flu-like symptoms, urgent care is your destination.

Do not rely on the ability of the urgent care doctors or nurse practitioners or physician’s assistants to screen you and decide whether you need to go to the emergency department or not.  They will do their best and send you on to the ER, if they think your condition is too serious for them or if it is one outside their ability to treat, but they sometimes make mistakes.  Because they are not usually highly trained emergency medicine physicians, they may not recognize the seriousness of your condition.  Even if they do recognize it, it may take a while and the time lost before you finally get to the ER may be critically important.

You are the critical decision maker when you are in need of medical treatment.  If it is potentially serious enough, call 911 and let the paramedics decide where to take you.  Don’t take a chance on urgent care, if there is any chance that you are really hurt or have a serious medical condition.

And when you get wherever you are going, remember how important a good history is to the person who is trying to figure out what is wrong with you.  Tell them everything you think may be important.  Be sure also to bring with you a list of all of the medications you are taking.  Have someone with you to keep you company and to keep an eye on the medical personnel to make sure you get taken seriously and get the treatment you need.

Posted in Board Certification, Cardiac CT scan, Doctors, Health Care Costs, healthy living, heart attack, Hospitals, medical errors, Medical Malpractice, medical mistakes, Medical Negligence, Misdiagnosis, Nurses, Stroke |

Melanoma Misdiagnosis.

November 09, 2020

If you, like me, live in Arizona, you are exposed to intense solar radiation nearly all year, but especially in the summer.  Exposure to solar radiation is one of the major risk factors for melanoma.

Melanoma - Wikipedia

Melanoma is a cancer, which most often appears on the skin.  It is a cancer of the melanocytes, the cells that produce brown pigment.  It can appear anywhere in the body there are melanocytes.  The most common area affected, other than the skin, is the eye.

Melanoma is forty times more common in whites than in blacks.  Men are more likely to develop it than women and people with many moles are at higher risk as well.  Fair-haired, white people, who burn easily or freckle, are among those at highest risk for development of melanoma.  Melanoma is the sixth most common cancer in Arizona and it is becoming more common all the time.

There is a good memory device to help you recognize melanoma, should it appear on your skin:  “ABCDE.”

A is for Assymetry.  The two halves of the spot on the skin do not match.  You can see that clearly in the image above.

B is for Border.  The spot has an irregular or scalloped border.

C is for Color.  The spot may have different colors, including black, brown, red, white or blue.  The image above shows different colors.

D is for Diameter.  Although they can be smaller, melanoma spots are usually at least the size of a pencil eraser.

E is for Evolving.  Watch for spots that are changing in size, color or shape.

The spot in the image above is a classic presentation for melanoma.  However, melanomas don’t always have classical presentations.  When they do not, they present the greatest chance for misdiagnosis arising out of a failure to recognize the presence of the melanoma.  Most of the melanoma cases I have handled have been failures by the physician to recognize a non-traditional presentation of melanoma.

One of my first melanoma cases involved a melanoma on the bottom of the patient’s foot.  Its location was probably the first thing which threw off the physician.  The bottom of the foot is not usually exposed to much solar radiation and is an uncommon location for a melanoma.  The failure to diagnose the melanoma was also a reaffirmation of the problem of unconscious biases, in this case confirmation bias.  The doctor did not expect to find a melanoma on the bottom of the patient’s foot and looked for and found a diagnosis that fit his pre-existing conclusion that this was not going to be a melanoma; he concluded it was a wart and tried unsuccessfully to burn it off.  The patient, a lovely, young woman with young children died shortly after we concluded her case.

When melanomas first appear on the skin, they tend to spread and may spread quickly.  During this phase of lateral spreading, they typically do not also grow deeply into the skin.  However, after growing out, they quickly begin to grow deep into the lower layers of the skin and the tissue below it.  It is when melanomas grow down that they also begin to metastasize to other parts of the body.

A melanoma, which is still on the top layers of the skin and has not begun to grow down, is a Stage I and can be treated with excision.  Melanomas addressed at this stage have good survival rates, usually exceeding 90% at five years.  If the melanoma has spread into the local area by the time of diagnosis, more than just excision will be necessary to treat it.  The 5 year survival rate for local melanomas is almost 60%.  On the other hand, if the melanoma has already spread to a distant site by the time of diagnosis, the 5 year survival rate is only 14%.

The lesson here is to be alert to the presence of possible melanomas and to see a dermatologist as soon as you recognize a spot which may be a melanoma.  If you see the doctor and he or she mistakenly says what you have is not a melanoma, you should go see an experienced malpractice lawyer.  Virtually any delay in the recognition of the presence of a melanoma can have fatal consequences as those 5 year survival rates show.  You need to see a lawyer as soon as possible after diagnosis.  Your claim is far more valuable to you and your family while you are still alive than it would be after you have passed.

Posted in arizona certified medical malpractice lawyers, Cancer, Doctors, health, medical errors, Medical Malpractice, medical malpractice cases, medical malpractice lawyers, medical mistakes, Medical Negligence, Melanoma, Misdiagnosis |