The Critical Value of Lab Tests

Many months ago our hospital "improved" the laboratory critical value list.

In the resulting tsunami of early AM phone calls for critically chronically low albumin levels in the malnourished, high bicarbs in lungers and multiple 3.4 meq/dl potassiums, one test stood out: INR/protimes.

I was called for every therapeutic(and many subtherapeutic 1.6+) INR on my warfarin patients.

I "improved" my results by ordering fewer tests, especially those I expected to trigger a call, until our medstaff successfully pushed back the expanded rules (see here for a study of the problem elsewhere). The INR standard was altered to accommodate anticoagulated patients, so the calls abated. Until today.

This morning I was called for a "critical" normal INR of 0.9 in a (non-anticoagulated) liver patient.

"hCG" Redux

I've seen much more of the "hCG" nonsense since my previous post.

I had a (very tall and obese) 11 year-old boy brought in by his father's female friend to receive my stamp of approval for "hCG" drops and the 500 calorie diet. She hoped to recruit me in her war against his mother (who refused the scheme, thinking it crazy).

Hal Dall, MD: "It's not appropriate, 500 calories are too few for a growing child".

Ms. Fireworks: (at 100 db) "Why do you want him fat?!? Do you want him dead? His mother is killing him"! etc. [rant]

HDMD: "He needs a balanced, moderately low calorie diet. 500 calories is too low".

Ms.F: "You want him fat? Why do you want him to get fatter?" etc. [rants more]

HDMD: "He'd lose weight on a balanced low calorie diet, and I'd be happy to refer him to a dietician for it".

Ms.F:(at 110 db) "That won't work!! He needs the "hCG"! He can't lose without it! His mother feeds him toasted cheese sandwiches! Is THAT the diet you want for him? Toasted cheese sandwiches? ...[rants longer and louder]

After a sharp exchange she accused me of child abuse for not giving approval to her scheme and she stamped out of the office.

I've not encountered the lady again, but the boy has since dropped from BMI 34 to 30.1 in the 8 months since his mom instituted a 1800 kcal diet with consistent exercise.

The Vast Medical Wing Conspiracy!

Doctors Conspire to Create Epidemics

Widespread Corruption Revealed By Informants


April 1, 2011
By Justin Kidding and April Fuel
Internet News Service

ALERT!! Your Doctor may be making you and your whole community sick!!

Our multi-hour investigation has exposed a massive conspiracy to spread illness organized by Chicago medical mobsters with corrupt doctors and pharmaceutical companies. Allegations of deliberate infections, kickbacks, and drug company trinkets have been raised by multiple personality insiders.

This elaborate scheme’s structure was revealed by our whistleblowers; “Dr. A”, “Dr.MD” and “Dr.HD” spoke to us on condition of strict anonymity. Each doctor tells an aspect of this many-faceted tale of conspiracy, greed and fear. Due to the sensitivity of the information and danger to our informants and ourselves, we will refer to the nefarious coordinating organization by the pseudonym “the American Mobster Doctor Association” aka the “AMDA”. We have confirmed and expanded on these allegations by consulting Google, Art Bell and Charlie Sheen.

We will start with the testimony of “Dr. A”, who gives the overview. “In spring we get the ‘wishbook’ from the “AMDA” which lists available pathogens. Our association reviews it and we make orders specifying germs and optimal timing of epidemics. It is required that a minimum 25% of the pathogens must be bacteria sensitive to antibiotics. In July we receive the (regionally) adjusted schedule, and the first enteroviruses appear. We order our influenza vaccine which is made to counter the 3 strains “AMDA” is using this year. In the fall, the first epidemics arrive, perhaps via jet contrails or ‘mosquito control’ spray trucks. Often a large daycare is contaminated to start things up or in smoke bombs at football games. Each month we promptly kickback part of our fees from office visits to the “AMDA” to ensure the next germ deliveries”.

How is Big Pharma involved? “The drug companies profit from the antibiotics, flu vaccines and cold medicines sold. They also help breed new flu strains to, ah, influence people to get another shot next year or else”. “Dr. A” adds, “I kept silent for years, but my loyalty ran out with the last ink from my final surviving free drug company pen”.

“Dr.HD” filled in some details. “Outbreaks are staggered around a region to decrease suspicion, the timing consistent with historical patterns. For example I might tell a parent, ‘It’s strep. We always get it this time of year’. Of course we do! As we ordered! Ha, ha, I have too much fun with it. I diagnose ‘what’s going around town’ the very day it started! And people whisper government conspiracy theories about black helicopters and I can smile, knowing it’s really the ‘AMDA’!”

“Dr. A” added, “The government is a party to it, though. Remember the saying, ‘Never let a virus go to waste’? The support of the ‘AMDA’ and Big Pharma was needed for the health care bill, so provisions hidden in the bill will continue the lucrative scheme. Of course there will be return payoffs to politicians from the profits through 'meaningful use' of EHRs. It’s the Chicago Way”.

We asked “Dr.MD”, With so many individuals in the know, how have doctors have kept this secret? She replied, “Fear. Naked fear. We know what they have, and they will not hesitate to use it on stool pigeons. C difficile. Vibrio. Entamoeba. Botulism. Even undercover sources are in danger from Treponema, Chlamydia, HIV, HPV and GC”.

It is as yet unclear whether hospitals are part of the syndicate, having no defections surviving from that quarter. Our questions of the “AMDA”were initially ignored, but after revealing our location were politely denied.

What can an individual do in the face of these threats? Unfortunately very little except wearing a little Japanese-style face mask and keeping your tinfoil hat in place.

There is no refuge from the contrails.

Expensive Ingredients

Recently a long-time patient asked my opinion of the 'new' weight-loss method becoming popular in our town. She has lost and regained hundreds of pounds over the years, trying various diets without long-term success. She did best with Weight Watchers, but a successful friend convinced her to try the "HCG" diet.

I scanned the pages of propagandvertising (the usual pseudoscientific rationale) and instructions she had been given. The diet was primarily very-low calorie (500 kcal/day) with periods of low calorie (1800 kcal) and had a long list of forbidden foods. No surprises there (as I told her, who won't lose weight on 500 Kcal/day?). In addition "HCG" drops are the magic ingredient- to be taken sublingually in 23 day cycles. HCG drops??

"Can I see the bottle they sold you"?

"Here it is. I paid $40 for it".

I look at the front of the label. " hCG". "homeopathic". I turn the bottle and see this on its side:

I turned the label toward her and she read aloud "Ingredients: Water."

"What! I paid $40 for WATER?!? How dumb was THAT"?

I Want The Drug Of Choice

A retired teacher recently presented with nontender quarter sized minimally red blotch on her leg. She told of recent treatment for a skin infection at an ED. She had no drainage to culture so was treated empirically with a cephalosporin, the infection rapidly diminishing but she soon stopped the med due to GI side effects leaving this minimal lesion. A few days later she came to my office, seeking further treatment.

Mrs. Surfer:I want linezolid for this. The Internet says it is The Drug Of Choice for skin infections.

Dr. Dall: It's used for severe, dangerous infections with possibly resistant staph. We try to hold it in reserve so we don't breed resistance.

Mrs. Surfer: I want the best medicine, it is what is recommended.

Dr. Dall: I'm not going to give it to you. Your infection is minor, non-threatening, and responded to an ordinary antibiotic and is essentially gone. You don't need a horrendously expensive IV medicine.

Mrs. Surfer:I want the best medicine, I don't care about the cost. I can pay for it if my insurance does not.

Dr. Dall: I'm not going to give it to you, I reserve it for specific circumstances.

Mrs. Surfer:Could you give me IV penicillin then? I won't take anything oral.

MMR Derangement Syndrome

BMJ published the first article in a series documenting how Andrew Wakefield falsified data to publish a purported link between the MMR vaccine and autism. Please read the article and commentary  in full (and future installments as they are published).

A summary from the BMJ article:

How the link was fixed

The Lancet paper was a case series of 12 child patients; it reported a proposed “new syndrome” of enterocolitis and regressive autism and associated this with MMR as an “apparent precipitating event.” But in fact:

Three of nine children reported with regressive autism did not have autism diagnosed at all. Only one child clearly had regressive autism

Despite the paper claiming that all 12 children were “previously normal,” five had documented pre-existing developmental concerns

Some children were reported to have experienced first behavioural symptoms within days of MMR, but the records documented these as starting some months after vaccination

In nine cases, unremarkable colonic histopathology results—noting no or minimal fluctuations in inflammatory cell populations—were changed after a medical school “research review” to “non-specific colitis”

The parents of eight children were reported as blaming MMR, but 11 families made this allegation at the hospital. The exclusion of three allegations—all giving times to onset of problems in months—helped to create the appearance of a 14 day temporal link

Patients were recruited through anti-MMR campaigners, and the study was commissioned and funded for planned litigation

The original paper fueled anti-immunization sentiment, and contributed to decreasing immunization rates and increasing infection rates across the Western world. Although the original paper was retracted last year by the Lancet, and Wakefield was stripped of clinical privileges in Britain, he remains a star of anti-immunization groups.

For his fraud, Wakefield gained fame and filthy lucre (including over $600000 from the legal firm). He remains unindicted, free to peddle his ideas here in the US.

The rest of us have paid a heavy price for these lies, in distrust and alienation between parents and doctors. In millions spent trying to disprove a fantasy. In children with preventable illness and untimely death. 

Handled By the Medical Safety Administration

Rejoice America! Help is on the way to rescue you from those ham-fisted unprofessional exams at airport screenings!

Soon, the Medical Safety Administration (MSA) will emerge from the Obama Health Insurance law to deliver you from unneeded medical screening exams, and will then (certainly) move on to non-medical ports of entry.

The US Preventative Screening Task Force (USPSTF) is the sole arbiter of medical screening in ObamaCare, so here are some highlights of USPSTF recommendations for the bashful:

NO recommended skin checks (visual or using scanner)

NO recommended ovary checks!

NO testicular exam!

NO rectal exams!

NO breast exams! Not even self breast exams!

SO, at your local MSA outpost(aka doctor's office)----no one will "TOUCH [YOUR] JUNK".

When the U.S. puts the MSA in charge of both medical and airport screening, all you hassled travelers can rest easy, at least until we get out the colonoscopes.

Risk Management

Today a cardiologist's office called. My referred 49 y/o patient refused her scheduled radionuclide cardiac imaging fearing danger from radiation exposure. Perhaps I can convince her that her cigarettes, liquor and methamphetamine are radioactive.

Peculiarities of Class

Nearly 20 years ago I had a young man present with a fractured a rib from a fall. I noted aloud the codeine allergy "documented" in his chart when I had first seen him 3+ years prior. I've never forgotten his response.

"Doc, I'm not allergic to codeine. I used to say that when I was still doing drugs so I could get Vicoden instead. We'd take 6 or 8 Vicoden at a time to get high, when I tried that with codeine, I'd just throw it up".

Drugs within the same class may (or may not) have significant differences in side effects (as above), intended pharmacologic effects(ditto) and cost. These differences are exploited by every player in the medical care bazaar.

My patient exploited differing intended and unintended side effects of two narcotics.

Drug reps exploit the most miniscule distinction to try to sell me on a product while talking down price disparity.

Insurance companies force choices due to cost while ignoring other considerations, regarding generic (same chemical) and same class (similar chemicals) as synonyms.

Recently I had a patient's spouse who explicitly adopted the latter view and was angry when I tried to explain the distinctions between one of his meds and her proposed substitute. "They're the same, there's no difference, they're in the same class".

The medicrats are smiling.

Dr. Rob's 10 Rules for Good Medicine

This superb post from Dr. Rob comes via DB's excellent blog.  Please go read it all.

A taste:

Rule 2: Minimize

Many doctors and patients have a “more is better” mentality. This not only costs more money to the system, but it can cause harm to the patient. Here’s what I think should be done:
1.  Patients should only be seen when a visit is appropriate.
2. Use as few medications as possible, and when necessary, use the cheapest one that will do the job.
3. Order as few tests as possible. No test should be ordered for informational purposes only; the question, “What will I do with these results?” should always be answerable. If it is not, the test should not be done.
4. When changes are made, make only a few at a time. Many simultaneous changes make it hard to tell what helps and what hurts.

If Dr. Rob's rules were followed, we'd waste less money to achieve better outcomes with less hassle and heartache.  Contrast these precepts of of professionalism to modern mandates by medicrats.