Jennifer Bunn, RN – Brain Blogger http://brainblogger.com Health and Science Blog Covering Brain Topics Sat, 30 Dec 2017 16:30:10 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.1 Fall Prevention – Who is Ultimately Responsible? http://brainblogger.com/2008/08/04/fall-prevention-who-is-ultimately-responsible/ http://brainblogger.com/2008/08/04/fall-prevention-who-is-ultimately-responsible/#comments Mon, 04 Aug 2008 13:05:15 +0000 http://brainblogger.com/?p=1121 It seems that as of October 1, 2008, Medicare will no longer be reimbursing hospitals for eight conditions that befall patients who are hospitalized, and that might have been reasonably prevented using certain evidence-based measures.

These eight conditions include:

* Pressure ulcers (bed sores)
* Objects left in patients during surgical procedures
* Falls suffered by patients while in hospital
* Blood incompatibility
* Air embolism
* Mediastinitis (infection of the area between the lungs)
* Urinary tract infections (UTIs) associated with indwelling catheters
* Sepsis that is central venous catheter-related

While some of these conditions appear reasonable (surgeons should not leave instruments in patients during surgery!), I have mixed emotions about the “falls” category.

HospitalWhile it is true that many falls can be prevented, some cannot. Sometimes patients do not follow the advice of their caregivers and persist in attempting to get out of bed on their own. This happens despite all side rails being up, a call bell situated within easy reach (sometimes pinned to their gown), and admonishment from staff not to attempt to get up by themselves. So who is to blame when patients fall, despite several safety measures in place?

The right to self-determination is a basic human right, and caregivers are sometimes placed in an awkward position, stuck between the proverbial rock and a hard place. Patients have the right to make decisions for themselves, don’t they?

Patients who are confused or who suffer from cognitive disorders may not have the ability to make wise decisions for themselves. These patients are often the ones who fall despite nursing staff’s best efforts. These patients often end up restrained, either physically, with the use of mechanical restraints, or chemically restrained using medications to calm them when they become agitated (meaning they are unwilling or unable to follow instructions not to get out of bed). This is done in an effort to prevent the patient from doing something that may result in an injury to themselves.

It seems that Medicare is placing the onus squarely on hospital personnel to prevent falls. At the very least, they won’t be paying the costs associated with falls suffered by patients in hospitals. My concern is that this policy will lead to an increase in the use of physical and chemical restraint in an effort to reduce the number of falls that hospitals will now be required to cover themselves.

While I agree that every effort should be made to prevent patients from falling while in hospital, I do not believe that falls can be prevented in every instance. Further, I do not believe that hospitals should be “punished” in those cases where falls occur despite the use of fall prevention strategies.

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Viruses Cause Cancer? http://brainblogger.com/2008/07/30/viruses-cause-cancer/ http://brainblogger.com/2008/07/30/viruses-cause-cancer/#comments Wed, 30 Jul 2008 21:01:13 +0000 http://brainblogger.com/?p=978 In the 11th Report on Carcinogens, the US government added Hepatitis C, Hepatitis B, and certain papilloma viruses to their list of substances known to be carcinogenic. This represented the first time ever that viruses were included.

At the sixth annual International Conference of the American Association for Cancer Research, Dr. Andrew J. Dannenberg stated, “I believe that, conservatively, 15 to 20% of all cancer is caused by infections, however, the number could be larger, maybe double.”

Dr. Dannenberg is director of the Cancer Center at New York-Presbyterian Hospital/Weill Cornell Medical Center. He went on to say, “Unfortunately, the public, as well as many health-care workers, are unaware of the significance of chronic infection as a potentially preventable cause of cancer.” Some examples he gave were liver cancer, caused by chronic Hepatitis B and C, and MALT lymphoma and adenocarcinoma of the stomach caused by Helicobacter pylori bacteria. Also, schistosome parasite infection has been implicated in bladder cancer (transitional cell carcinoma) .

Probably the most well known example is HPV, or human papilloma virus, known to cause genital warts and now known to be the major cause of cervical cancer. According to the National Cancer Institute, 11,000 women were diagnosed with cervical cancer in 2007, and nearly 4,000 of these would die from it. Oropharyngeal cancer is also thought to be caused, in some cases, by HPV infection and past HPV exposure.

The FDA approved Gardasil vaccination in 2006 to prevent infection against high-risk HPV’s known to cause cervical cancers and genital warts. Gardasil is approved for use in girls only, and can be given as young as nine years of age. This has led to some questions as to why the vaccine is not offered to boys if it is known that HPV causes oropharyngeal cancer as well as vaginal cancer. This may be because the vaccine is expensive and oropharyngeal is rare in comparison to cervical cancer.

What does the future hold for virus research? Likely much more research will be done to attempt to identify which viruses are associated with certain types of cancer. If this can be accomplished, perhaps the key to fighting cancer in the future will be to prevent people from getting cancer in the first place. If scientists can create a vaccine like Gardasil to prevent cervical cancer, it is not out of the realm of possibility to hope that some day they will come up with a vaccine for all cancers. One can always hope.

Reference

Report on Carcinogens, Eleventh Edition; U.S. Department of Health and Human Services, Public Health Service, National Toxicology Program.

Further Reading

Human Papillomaviruses and Cancer: Questions and Answers; National Cancer Institute, US National Institutes of Health.

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Emergency Rooms – Overcrowded and Understaffed http://brainblogger.com/2008/07/24/emergency-rooms-overcrowded-and-understaffed/ http://brainblogger.com/2008/07/24/emergency-rooms-overcrowded-and-understaffed/#comments Thu, 24 Jul 2008 13:35:30 +0000 http://brainblogger.com/?p=1078 Who is to blame when patients die in overcrowded and understaffed emergency rooms?

The story of the death of a psychiatric patient in a large Brooklyn, New York hospital got my attention, both as a nurse and as a human being. These stories are, thankfully, rare but still happen too frequently. In this case, lack of a bed for the patient was cited as the reason the patient was in the ER for almost 24 hours. The patient was reportedly suffering from a psychiatric condition, but deaths of patients have occurred in emergency rooms among patients with medical conditions as well.

Who is responsible when patients die in emergency rooms, sometimes while they are awaiting care? Can overworked ER doctors and nurses be held liable when patients die in these circumstances?

Emergency RoomI can recall waiting 17 hours in a large hospital waiting room with a family member, who spent much of the time in the hallway on a stretcher waiting for a bed to become available. We were told our chances of getting a bed would be better in the morning, after doctors had made their rounds and discharged some patients. I remember feeling angry that the wait was so long, but also feeling some compassion for the staff that I watched throughout that long night, running constantly and looking harried and exhausted. My two sides, anxious family member and professional nurse, warred with each other. I don’t recall ever feeling ignored or that no one cared about our situation, but I did feel a great amount of frustration that our health care system, in one of the richest countries in the world, could be like this.

Angry family members are much more likely to find themselves in a litigation frame of mind. Could not more be done to “soothe the savage beasts” in the waiting rooms of the busy and overcrowded emergency rooms? It is my humble opinion that one way of alleviating the bad moods of waiting patients would be to have a circulating staff member (perhaps a nurse or paramedic) whose sole responsibility would be to offer understanding and comfort to those waiting for long hours to be seen by a doctor. The current triage system practiced in most hospitals does not allow for such handholding.

Such a simple thing… but it could make a big difference to those forced to wait, and cause them to look a little more favorably upon those who are doing the best they can in trying circumstances.

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The Eighth Leading Cause of Death in the U.S. is… http://brainblogger.com/2008/07/20/the-eighth-leading-cause-of-death-in-the-us-is/ http://brainblogger.com/2008/07/20/the-eighth-leading-cause-of-death-in-the-us-is/#comments Sun, 20 Jul 2008 17:03:06 +0000 http://brainblogger.com/?p=993 Health and Healthcare CategoryThe eighth leading cause of death in the U.S. is medication error. This statistic may surprise you. Other frightening statistics include the following:

* 7,000 deaths occur each year that are directly attributable to medication errors.
* Errors occur around 1 in 5 times that medication is administered.
* The FDA estimates 1 death per day due to medication errors.

The three most common errors are giving an improper dose, giving the wrong drug, and giving the drug by the wrong route (for example, intravenous instead of oral).

MistakesEveryone involved in health care is aware of errors and know that they occur more often than they should. The question then becomes:

If it is known that errors are happening, what can be done to prevent them?

Nursing personnel are the front-line staff most often responsible for administering medications to patients. Any factor that decreases the effective functioning of nursing staff will impact how safely nurses can perform their duties.

The nursing shortage impacts nursing care in a negative way. A shortage of nursing staff translates to fewer nurses to care for the same amount of patients. The shortage of nurses also means that nurses are working overtime more often, and coming in to work on their days off more often. Nurses often work in excess of 12 hours a day. All of these factors add up to fatigue and stress, a double whammy when it comes to human error.

Hospitals are now turning to technology to attempt to decrease hospital medication errors. Computer-generated prescriptions cut down on errors that occur in transcribing doctor’s orders. In some centers, nurses are being provided with hand-held computers that contain drug information on dosing, routes, and adverse effects. Medications are being provided in single-dose packaging, and drugs that have names similar to other drugs are packaged differently and include clearer labeling. Dangerous medications are signed for by two staff members instead of one (for example, insulin, narcotics, and anticoagulants). Abbreviations that are dangerous or misleading have been abolished in some cases.

Patients are now becoming more educated about their medications, their conditions, and their treatment, but too many still blithely accept medications and treatments without asking questions of health care personnel. All too often, patients are not aware of the names, correct doses, and prescribing reasons behind the medications they are on. Questioning medical personnel about their medications and why they are being given these medications is one way that patients can help safeguard themselves.

The nursing shortage is not likely to end any time in the near future. Decreasing the risk of medication errors is the job of all medical personnel who care for patients. Doctors can do their part by writing (or printing) orders legibly and clearly stating their orders with no ambiguity. Nursing staff who administer medications need to take advantage of all technology available that may help them do their jobs more safely. Finally, patients need to be their own best advocates by being fully aware of their treatment plan and medications. If a patient is unable to understand, a family member or friend can take on this role.

To err is human but, by working together, hospital personnel can help reduce the staggering statistics of medication error.

Reference

Kramer, J.S., Hopkins, P.J., Rosendale, J.C., Garrelts, J.C., Hale, L.S., Nester, T.M., Cochran, P., Eidem, L.A., Haneke, R.D. (2007). Implementation of an electronic system for medication reconciliation. American Journal of Health-System Pharmacy, 64(4), 404-422. DOI: 10.2146/ajhp060506

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The Ethics of Selling Prescription Data http://brainblogger.com/2008/07/17/the-ethics-of-selling-prescription-data/ http://brainblogger.com/2008/07/17/the-ethics-of-selling-prescription-data/#comments Thu, 17 Jul 2008 13:27:07 +0000 http://brainblogger.com/?p=1048 Health and Healthcare CategoryThe compilation and selling of physician prescribing habits has been a common practice since the 1990’s. Many physicians were unaware that the issue was occurring.

Pharmaceutical companies argue that the mining of prescribing data has beneficial uses, such as providing information about drug interactions and long-term effects, and prevention of drug errors. Pharmaceutical companies have also stated that without the use of this information, they would be less able to target educational information. Doctors would see an increase in sales calls and a decrease in needed drug samples.

FilesDoctors argue that the choice should be theirs as to whether or not their prescribing practices should be sold to drug companies. According to a national survey conducted for the AMA in 2004:

77 percent were unaware that pharmaceutical companies had access to physicians’ prescribing data, and 66 percent opposed the release of these data to sales representatives. However, 68 percent believed that the release of the data had “neither a particularly positive nor a particularly negative impact on their medical practices”; 77 percent indicated that their concern would be alleviated if they were given the choice of preventing the release of their prescribing data to sales representatives.

In 2005, the AMA claimed $45.5 million in revenue from the sale of database products. Their Masterfile contains information on 820,000 physicians (December 2004). Although it does not contain prescribing data, it does contain historical data from a doctor’s time as a medical student onward. Pharmaceutical companies can cross-reference this information with information obtained from other sources, such as internal identifiers used by pharmacies, and come up with a profile of a doctor’s prescribing history.

This is a very lucrative business:

In 2005, IMS Health had operating revenue of $1,75 billion, substantially all from sales to the pharmaceutical industry.

The AMA mitigated the situation by producing the Prescribing Data Restriction program, which allows doctors to deny access to their prescribing habits to all sales representatives and their supervisors. The web-based program commenced in May of 2006. They did not, however, stop the practice of selling their Masterfile to companies who mine the data contained within to discern prescribing data and patterns. They have justified their decision to continue licensing their Masterfile with the argument that if they do not, their revenues will decrease and pharmaceutical companies will find the information from another source.

Reference

Steinbrook, R. (2006). For Sale: Physicians’ Prescribing Data. New England Journal of Medicine, 354(26), 2745-2747. DOI: 10.1056/NEJMp068125

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Charity Begins at Home – U.S. Physicians Volunteer http://brainblogger.com/2008/07/09/charity-begins-at-home-physicians-volunteer/ http://brainblogger.com/2008/07/09/charity-begins-at-home-physicians-volunteer/#comments Wed, 09 Jul 2008 15:51:29 +0000 http://brainblogger.com/?p=995 Health and Healthcare CategoryOne of the biggest crises facing the United States today is healthcare. There are approximately 47 million people in the United States who have no medical insurance. Millions more have inadequate insurance coverage, cannot afford their premiums or deductibles, and have no access to dental care.

In the wake of recent international disasters (Myanmar and China to name the most recent), much publicity has focused on foreign aid. The U.S. spends billions of dollars every year to help those less fortunate in other countries.

But are they doing enough for their own citizens?

The Magnificent MileCBS reported on an unusual occurrence in Tennessee in February of this year. Remote Area Medical, originally founded to provide medical aid to remote parts of the world, set up a free clinic in an exhibit hall in Knoxville. Within hours, they had all the work they could handle as people drove hundreds of miles to camp in the parking lot, hoping to be allowed access to the free medical, dental, and optometry services offered by volunteers.

According to the American Medical Association (AMA), nearly 65% of approximately 518,195 post-residency patient care physicians provided care to the indigent in 1999. In a Board of Trustees Report, the AMA Foundation discussed methods to support health services for the uninsured.

Out of their recommendations it is apparent that many physicians are willing to volunteer their time and expertise to caring for indigent patients. However, they are often required to pay for their own licensing requirements and insurances. Because many of the physicians who volunteer are retired, these fees (which can be quite steep) are sometimes a deterrent to volunteerism.

One way to help those patients who cannot afford healthcare would be to take advantage of retired doctors who want to serve the poor. States could pay licensing fees for these volunteer doctors, and could also provide insurance coverage in return for a minimum number of hours of service.

Some states have taken the initiative in offering licenses free of charge to volunteer physicians who serve only indigent patients or who serve in areas that are underserved. Some states offer licenses at a reduced fee. Some states have adopted legislation to limit liability of volunteers. The Volunteer Protection Act, passed in 1997, sets a minimum national standard for immunity laws for volunteers. Although it sets limits on awards, it still does not provide full protection and physician volunteers, or the organizations they work for, are still responsible for medical liability insurance.

With a large number of retired physicians who are civic-minded, states could go a long way towards easing the burden of the uninsured by making it easier for retired physicians to do what they do best.

Reference

Rooney, W.R. (2003). Maintaining a Medication List in the Chart. Family Practice Management, 10(1), 52-54.

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Ethical Obligations of Health Care Workers During a Pandemic http://brainblogger.com/2008/07/04/ethical-obligations-of-health-care-workers-during-a-pandemic/ http://brainblogger.com/2008/07/04/ethical-obligations-of-health-care-workers-during-a-pandemic/#comments Fri, 04 Jul 2008 13:05:21 +0000 http://brainblogger.com/?p=1057 Health and Healthcare CategoryThe article I posted a few weeks ago in regards to the H5N1 vaccine caused me to consider a potential pandemic and the health care workers’ obligation to work should the event come to pass.

The World Health Organization estimates that

today a pandemic is likely to result in 2 to 7.4 million deaths globally. In high income countries alone, accounting for 15% of the world’s population, models project a demand for 134-233 million outpatient visits and 1.5-5.2 million hospital admissions.

Prepare For DisasterThe romantic notion of selfless sacrifice in medicine may be the exception rather than the norm in the face of a global pandemic, which would stretch our already over-stretched resources to the breaking point. Although history has given us many noble figures in medicine, how noble will we be if we are faced with a highly virulent strain of flu to which none of us are immune, and to which a vaccine to prevent the illness might not be available until after the outbreak of the disease has already begun?

There is a precedence for this,

during the early years of the Human Immunodeficiency Virus (HIV) epidemic doctors debated whether it was acceptable to refuse to treat those with HIV; and during the Severe Acute Respiratory Syndrome (SARS) outbreak some HCW’s were not willing to treat SARS patients.

Fear is a powerful motivator. Although health care workers generally are a selfless lot, many health care workers may refuse to work during a pandemic due to fear for their own safety and that of their families. Is it ethically wrong to refuse to work if a spouse or a child becomes ill? To what extent are health care workers expected to put the welfare of others above their own, or their children’s, needs?

In the US Armed Forces, soldiers who go AWOL (absent without leave) can be severely punished, including a jail term. Can (or should) health care workers be held to the same standard, which boils down to duty to country first and personal concerns last?

I don’t have any answers to these questions. This issue will have to be addressed personally by all health care workers who are involved in direct patient care. When the time comes, we will all be faced with hard decisions.

The only thing I am sure of is that this issue should be planned for and thought about before the time comes that the notion of self-sacrifice must be put to the test.

Reference

Draper, H., Wilson, S., Ives, J., Gratus, C., Greenfield, S., Parry, J., Petts, J., Sorell, T. (2008). Healthcare workers’ attitudes towards working during pandemic influenza: A multi method study. BMC Public Health, 8(1), 192. DOI: 10.1186/1471-2458-8-192

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Should Patients with Schizophrenia Receive Free Medication? http://brainblogger.com/2008/06/28/should-patients-with-schizophrenia-receive-free-medication/ http://brainblogger.com/2008/06/28/should-patients-with-schizophrenia-receive-free-medication/#comments Sat, 28 Jun 2008 12:45:24 +0000 http://brainblogger.com/?p=1067 Psychiatry and Psychology CategoryA recent study from Harvard Medical School found that restrictive drug programs might cause schizophrenia patients to stop taking their meds. Nearly 80% of patients without antipsychotic medication will have a serious recurrence of their illness within a year.

The study focused on Medicare beneficiaries with schizophrenia in the state of Maine and a policy (step program) that required schizophrenia patients to use a Medicare-approved medication before they were allowed to be prescribed drugs not on the “approved” list. In comparison with patients in states with no such restriction, schizophrenia patients in Maine were 29% more likely to stop taking their meds.

UnrealThis policy seems to be yet another example of bureaucratic mismanagement. It seems obvious that the savings accrued from forcing schizophrenic patients to take medication that they feel is ineffective in controlling their symptoms (and that they ultimately quit taking) would be far outweighed by the cost of treating schizophrenia patients for a serious reoccurrence of their illness, likely in a hospital or psychiatric ward setting.

Perhaps we would be further ahead monetarily to cover the entire cost of prescription drugs for patients who suffer from schizophrenia, making it more likely that they take their medications regularly, and preventing costly relapses.

We could test this theory by comparing schizophrenia patients and their reoccurrence rates in the U.S. against the same population in a country such as Canada, where schizophrenia patients are covered under free health care plans. If the null hypothesis was true, and there is no difference in the populations, my theory doesn’t hold much water.

However, given the fact that 1% of the population in the U.S. suffers from schizophrenia, which translates to approximately 3 million people, it may be worth testing the theory. Paying for all of their prescription drugs would cost a large sum of money. Then again, so does paying for repeated treatment for reoccurrences of their disease caused by failure to take their medications. At the very least, there should be no restrictions on medications that may be prescribed to them by their doctors, who can be assumed to know them best, as opposed to government employees who make such decisions about health care.

Reference

Soumerai, S.B., Zhang, F., Ross-Degnan, D., Ball, D.E., LeCates, R.F., Law, M.R., Hughes, T.E., Chapman, D., Adams, A.S. (2008). Use Of Atypical Antipsychotic Drugs For Schizophrenia In Maine Medicaid Following A Policy Change. Health Affairs, 27(3), w185-w195. DOI: 10.1377/hlthaff.27.3.w185

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Should Doctors be Paid by Drug Companies for Research? http://brainblogger.com/2008/06/25/should-doctors-be-paid-by-drug-companies-for-research/ http://brainblogger.com/2008/06/25/should-doctors-be-paid-by-drug-companies-for-research/#comments Wed, 25 Jun 2008 14:38:01 +0000 http://brainblogger.com/?p=994 Drugs and Clinical Trials CategoryAs research has moved away from the realm of universities and into the private sector, more physicians are being paid by drug companies to enroll and monitor patients during clinical trials. Private corporations have been the largest sponsors of pharmaceutical research in both Canada and the United Sates in the last twenty years.

Research Ethics Boards (REB’s) exist to protect the safety of research subjects. However, they provide guidelines only, and often guidelines are ambiguous. REB’s may be private entities, and thus may be vulnerable to pressure.

MoneySome of the concerns raised in regards to physician remuneration question whether physicians can maintain objectivity. Physicians may not fully disclose all potential risk factors to patients if it is in their financial interest to recruit subjects for a trial. Another concern is the potential for breech of confidentiality. A breech could occur if physicians actively search for likely candidates for a drug trial by accessing charts of patients who are not theirs. Physicians may also be tempted to enroll patients in a trial who do not meet the criteria for selection, or patients who are “on the cusp.”

Patients may also feel some pressure to agree to enroll in a study strictly because of the nature of the physician-patient relationship. Patients place great trust in their doctors, but they may be afraid that refusing to take part in a study may cause their doctor to have negative feelings towards them. They may agree to take part simply to keep their doctor “happy.”

Another concern is that financial inducements may hamper physician’s decision-making. For example, a doctor who was being rewarded financially for every patient who completed the study might be inclined to keep a patient in the study even if they suffered untoward symptoms.

There are internationally developed guidelines that are meant to provide guidelines in clinical research; some examples are the Helsinki Declaration, International Guidelines for Biomedical Research Involving Human Subjects, and Good Clinical Practice for Trials on Pharmaceutical Products (World Health Organization).

What are some considerations that can mitigate some of the aforementioned conflicts of interest? Above all, patients should be made aware of any potential conflict of interest and also have the right to know exactly how the physicians are being rewarded by the drug company. Additionally, patient confidentiality should be protected as much as possible and patients should be made aware of how information about them may be shared. In this way, physicians can participate in research trials without compromising patient trust and safety.

Reference

Puttagunta, P., Caufield, T., Grenier, G. (2001). Conflict of Interest in Clinical Research: Direct Payment to the Investigators for Finding Human Subjects and Health Information. Health Law Review, 10(2)

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Clinical Trial for H5N1 Bird Flu Vaccine http://brainblogger.com/2008/06/14/clinical-trial-for-h5n1-bird-flu-vaccine/ http://brainblogger.com/2008/06/14/clinical-trial-for-h5n1-bird-flu-vaccine/#comments Sat, 14 Jun 2008 14:50:09 +0000 http://brainblogger.com/?p=1049 Drugs and Clinical Trials CategorySince the virus was first detected in Guangdong Province, China in 1996, H5N1 (Bird Flu) has received much attention as the fear of a global spread of the disease mounted. Initially, H5N1 was considered merely interesting; however, alarm bells began to ring when it spread through live-poultry markets in Hong Kong, and eventually to humans, in 1997. The virus killed 6 of 18 infected people.

Now, a published clinical trial of a whole-virus H5N1 vaccine derived from a cell culture raises new hopes for a vaccine against the deadly virus.

Bird FluSince 1997, we’ve determined that the virus continues to evolve and mutate. In an effort to control spread of the disease, millions of birds have been slaughtered and disposed. Thus far, 45 countries have reported Bird Flu outbreaks. The virus is endemic in dozens of species of birds in South Asia, and is threatening to become endemic in west Asia and Africa.

Currently, it is very difficult for humans to become infected with H5N1; however, intermittent spread to humans will continue as the virus evolves. The current number of confirmed cases of Bird Flu reported to the World Health Organization (WHO) as of May 2008 is 383 cases. Of these, 241 have died.

The whole-virus vaccine was created using a strain from A/Vietnam/1203/2004 obtained from the CDC and inactivated. The vaccine was manufactured in Vero cell culture.

The results as published found that,

… the vaccine induced a neutralizing immune response not only against the clade 1 (A/Vietnam/1203/2004) virus strain but also against the clade 2 and 3 strains.

The researchers conclude that

this may be a useful H5N1 vaccine.

The study raises hopes that a vaccine will be available should the (some say) inevitable come to pass, and we are faced with a pandemic the likes of which we have not seen in a long time. But who will decide who gets the vaccine if and when the time comes? Currently, our ability to manufacture a flu vaccine is not great enough to supply the vaccine to everyone. Although this issue is being addressed, it will likely become an issue of contention.

Pandemic planning is aimed at getting the vaccine to “front-line” workers first, as these people will be necessary to controlling the spread of the disease; for example, health care workers who will be caring for victims of the flu, and the military, who will be charged with keeping the peace among citizens.

Will our public health measures be adequate in the face of an epidemic? What will the role of health care workers, and their obligation, be? When it is inevitable that the number of sick far outnumber the workers that are available, what ethical obligation will health care workers be held to?

And what of countries who will not be able to afford to vaccinate their citizens? What will they do? Will our government step in and provide the vaccine to them? Or, will it become a matter of the “haves” and the “have-nots,” with developing countries being left to fend for themselves (as they too often are)?

Likely, when the time comes, the fact that a vaccine is available will not be a guarantee that everyone will have equal access to it.

References

Ehrlich, H.J., et al. (2008). A Clinical Trial of a Whole-Virus H5N1 Vaccine Derived from Cell Culture. NEJM, 358(24), 2573-2584.

Cumulative Number of Confirmed Human Cases Of Avian Influenza A (H5N1) Reported to WHO. May 28, 2008.

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The Implications of Implanted Chips http://brainblogger.com/2008/06/09/the-implications-of-implanted-chips/ http://brainblogger.com/2008/06/09/the-implications-of-implanted-chips/#comments Mon, 09 Jun 2008 15:28:18 +0000 http://brainblogger.com/?p=976 In June of 2007, the American Medical Association’s Council on Ethics and Judicial Affairs stated, “RFID tags may promote the timely identification of patients and expedite access to their medical information. As a result, these devices can improve the continuity and coordination of care with resulting reduction in adverse drug events and other medical errors.”

Approved by the FDA in 2004 and marketed by the VeriChip Corporation, the VeriChip is a microchip about twice the length of a grain of rice. It is implanted below the skin and above the triceps area of the patient’s right arm. The procedure can be performed in a doctor’s office after a local anesthetic is given to numb the area.

The VeriChip contains a 16-digit number that, once scanned at the right frequency, can provide information on the patient’s health. The subscriber controls information in the database. A VeriChip reader is needed to gain access to the information in the database. Hospitals who become part of the system are provided with a secure logon, and a record is made anytime anyone accesses a subscriber’s information.

Potential medical complications of chip insertion are infection of the tissue at the site of implantation and migration of the chip. There have been studies that have shown a small risk of tumors in small lab animals that were implanted with RFID’s, but there is no evidence that VeriChip has ever caused such a problem.

One of the biggest medical concerns with the VeriChip is that patients who have one implanted may not be able to undergo an MRI. A MRI (magnetic resonance imaging) is a valuable test that can image different tissues and does not use radiation. Any implanted device containing metal such as a pin, plate, screw, or artificial heart valve, to name a few, can cause patient burns when the patient undergoes a MRI. The recommendation is that only VeriChip patients who are awake and alert should have a MRI exam, so that they are able to alert medical personnel if they feel any heating of the implant.

The other obvious issue, and perhaps the most important one, is that of privacy. Although the chip contains only a 16-digit number and one would need to be in possession of a VeriChip reader and an access code, it seems possible that others with no right to your personal information could find a way to get it.

Although undoubtedly designed with good intentions, the risk for abuse of patient privacy in this situation is difficult to ignore. Time will tell. In the meantime, one can always wear a MedicAlert bracelet. They’re cheap, and you can take them off before you climb into that MRI machine.

References

Sade, RM. (2007) Report of the Council on Ethical and Judicial Affairs. CEJA Report 5-A-07.

Holtzman, DH. Human ID Chips Get Under My Skin. BusinessWeek. February 12, 2008.

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The Great Embryonic Stem Cell Debate http://brainblogger.com/2008/05/28/the-great-embryonic-stem-cell-debate/ http://brainblogger.com/2008/05/28/the-great-embryonic-stem-cell-debate/#comments Wed, 28 May 2008 16:59:13 +0000 http://brainblogger.com/?p=990 Neuroscience and Neurology CategoryPerry Cross, a ventilator-dependent quadriplegic, traveled to India to receive daily injections of stem cells. He claims that, owing to the stem cell treatment, he is now able to breathe on his own for the first time since a rugby injury made him a quadriplegic 14 years ago. The breakthrough is likely to fire up the stem cell debate once again.

There are no approved treatments or human trials in the U.S. using embryonic stem cells, thus the need for Cross and his team of care workers to travel to India, where the controversial Dr. Geeta Shroff operates two hospitals. In India, embryonic stem cell treatment is allowed for patients who are terminal or who have incurable conditions. Perry Cross is not her first international patient. Patients come to Dr. Shroff from countries where embryonic stem cell research is strictly controlled, countries such as the U.S., Australia, and Britain.

Human Embryo at Seventh WeekThe debate over stem cell research has raged since scientists first postulated that embryonic stem cells, because of their ability to differentiate, could potentially be used to treat a myriad of conditions, from paralysis to brain damage to diseases such as Multiple Sclerosis and Parkinson’s. Well-known public figures have added their voices to the debate (Christopher Reeves, Michael J. Fox).

The crux of the stem cell debate is that using the stem cells means destruction of the embryo. Opponents of embryonic stem cell research raise several moral and ethical objections. The meat and potatoes of their arguments are the same arguments that have divided people on the abortion issue; namely, when does life begin? Those who are against stem cell research using human embryos revere human life and believe that conception is when life begins, therefore using embryos for research or treatment is tantamount to murder. They raise the point that research should be directed towards adult stem cell research (as do the researchers who are studying adult stem cells). Studies have shown that embryonic stem cells can create tumors, and that cells that are created for therapeutic cloning may cause rejection.

Proponents of embryonic stem cell research argue that life begins only when a heart beat or brain activity can be detected. They argue that abortion is now legal in several states and countries and the “by-products” would be wasted, therefore they should be used for stem cell research. A similar argument is that, through the science of in-vitro fertilization, many embryos are created that must later be stored or destroyed. These embryos could be used (with permission) for research. Proponents raise the issue that the benefits of stem cell research to mankind outweigh the “cost.”

Dr. Shroff has many detractors in the science community. She has not published any results of her work and also has a patent pending. Other scientists have raised concerns that, because she does not publish her work, it is difficult to know if her treatments will have any lasting effect or, worse, adverse effects. She has been accused of using patients as guinea pigs.

If more patients, like Perry Cross, advertise success with embryonic cell treatments, it is likely that there will be an increased clamor for a relaxation of the laws in countries that strictly control such research.

Perry Cross is a happy guinea pig.

Even if I managed to move a finger or one hand, it would be worth it.

Reference

Australian Quadriplegic Thanks Maverick Indian Stem Cell Doctor for Ability to Breathe. May 27, 2008.

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Should Doctors Be Allowed To Refuse Treatment? http://brainblogger.com/2008/05/25/should-doctors-be-allowed-to-refuse-treatment/ http://brainblogger.com/2008/05/25/should-doctors-be-allowed-to-refuse-treatment/#comments Sun, 25 May 2008 14:45:22 +0000 http://brainblogger.com/?p=975 Health and Healthcare CategoryShould doctors be able to turn patients away if they disagree with their lifestyle choice?

The article reads like many pregnancy stories. The happy couple finally become pregnant against all odds and eagerly anticipates the birth of their first child. This story, however, takes a twist that many people, including doctors, find hard to fathom.

In this case, the expectant mom is a transgender male, recognized as a male by law.

Himself herselfThomas Beatie was born a female but made the decision to pursue sex reassignment. He underwent chest reconstruction and testosterone therapy, but stopped short of removal of his female organs. Two years ago he and his wife, who is unable to bear children herself, made the difficult decision that Thomas would be the one to carry their child. He stopped taking testosterone and, within four months, was experiencing normal female cycles.

What began then was a battle to find a doctor willing to take on their unusual situation. Thomas explains,

In total, nine different doctors have been involved. This is why it took over one year to get access to a cryogenic sperm bank to purchase anonymous donor vials, and why Nancy and I eventually resorted to home insemination.

There are many other stories out there. Perhaps they are not as controversial as Thomas’s story, but the underlying issue is the same. Should physicians be able to refuse treatment to a patient based on their negative perception of the patient, or the values they ascribe to them?

There have been many cases reported of doctors refusing to prescribe birth control, anesthesiologists refusing to take part in sterilization surgery, and, of course, the ever popular abortion debate.

In a study published in The New England Journal of Medicine, 63% of doctors said that they felt it was acceptable to tell patients they have moral objections to treatments, and 18% felt they had no obligation to refer these patients elsewhere.

Patients who are refused treatment are not likely to complain; they quite often feel humiliated but simply seek care elsewhere and put the episode behind them. They don’t often have the opportunity to complain to as wide an audience as Thomas did.

The problem with the physician’s right to refusal to treat patients who do not adhere to their own moral compass is that lines can become blurred. Take the following example:

A mother and her daughter were turned away from a doctor’s office because the mother had a visible tattoo. The doctor claimed he was a Christian and that he was simply creating a Christian atmosphere for his patients.

What is disturbing about these stories, extreme as they may seem, is that once discrimination is allowed against one group, it becomes easier to discriminate against another.

References

Beatie T. Labor of Love. The Advocate. April 8, 2008.

Curlin, F.A., Lawrence, R.E., Chin, M.H., Lantos, J.D. (2007). Religion, Conscience, and Controversial Clinical Practices. New England Journal of Medicine, 356(6), 593-600. DOI: 10.1056/NEJMsa065316

Erdely SR. Doctors’ beliefs can hinder patient care. MSNBC. June 22, 2007.

Christian pediatrician denies child service because parents are tattooed. Evangelical Right. February 16, 2007.

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