Shock Media

"U.S. Deaths From Staph Surpass AIDS" says the AP. The first line of the article reads "About 18,700 people die in this country each year from drug-resistant staph infections, according to a federal study released Tuesday — more deaths than the United States sees from AIDS annually." This number comes from a CDC study on MRSA published in today's JAMA (JAMA 2007;298:1763-1771). Using the number of yearly AIDS deaths in the US cited in the Chronicle article, 17,000, then 1,700 more people die in the US every year from MRSA.

When reading the actual study, though, I get a slightly different feel.

Basically, the authors used a CDC surveillance procedure, monitoring 9 large urban areas for cases of MRSA, then obtaining medical records for each patient. Outcomes--death or discharge--were taken from the medical record.

Here's the thing, though: they never stated explicitly that the cause of death was MRSA. It's easy to imagine that a person with an invasive MRSA bacteremia would be critically ill, but how does one determine that the MRSA killed them, or the kidney failure which had them requiring dialysis which led to them getting MRSA in the first place? Or if someone is recovering from MRSA sepsis with DIC, then throws a massive pulmonary embolism and dies from being in the ICU for weeks, is the cause of death MRSA? It's also possible that a patient had a positive MRSA culture from a cellulitis, but died of something entirely unrelated, like an MI or CHF. They never stated that the cause of death was MRSA, only that these people a) had an invasive MRSA infection and b) died. If MRSA wasn't the direct cause of death in all of these patients, then the rate of death due to MRSA would be lower than they predicted.

Also, the only record of death came from the medical record for patients who died in the hospital. It's feasible to imagine that some patients died at home or in nursing homes from MRSA or its complications who weren't included. This would mean the rate could be higher than they estimated. Lastly, we're assuming that these 9 regions represent the US as a whole, but in reality bacterial populations vary by geographical regions. One of the sites studied, Baltimore, was left out of incidence calculations because it had much higher rates than the other 8 sites.

The point of the article was really to show that the rate of invasive MRSA infections is higher than previously supposed, and that a substantial amount of these infections came from the community. The majority of infections and deaths came from the healthcare-associated disease--patients who have been hospitalized recently, or have indwelling catheters and lines, or dialysis, or live in nursing homes, etc. Healthcare-associated infections also tended to be a more dangerous strain, USA100, with more multi-drug resistance, compared to community-acquired infections. Interestingly, although they gathered the data about the strain and presented it in the results section, they give it only a few sentences in the conclusion, as if the incidence data is so much more interesting.

Much of what got quoted in the Associated Press was an editorial about the study, also in today's JAMA (2007;298:1803-1804). This is where the comparison to AIDS comes from and some of the other quotes used in various articles about this study today.

Naturally, MRSA is a huge problem. Isolates at one hospital I work at have developed alarming tolerance of vancomycin--not high enough to be considered vancomycin-resistant, but high enough that the concentration of vancomycin required for treatment is reaching dangerous levels. This hospital is considering a policy change to make linezolid the first choice antibiotic for MRSA. We're one step closer to VMRSA, a much scarier beast.

Most hospitals are not required to report MRSA rates (or any other drug-resistant bacteria) to authorities. Some hospitals have started nasal swab policies to identify MRSA carriers upon admission to isolate them sooner and prevent the spread to other patients. Hand washing policies are effective against the spread of nosocomial infections, but are sadly under-enforced.

I'm always a little amused by what the popular media will choose for their headlines, however. I guess they made their point: everyone knows about and fears AIDS, but few people know about MRSA.

Emotional Rollercoaster, or The Power of Denial

We've all heard the term "denial". It has several meanings:

A refusal to comply with or satisfy a request.

1. A refusal to grant the truth of a statement or allegation; a contradiction.
2. Law The opposing by a defendant of an allegation of the plaintiff.
3. A refusal to accept or believe something, such as a doctrine or belief.
4. Psychology An unconscious defense mechanism characterized by refusal to acknowledge painful realities, thoughts, or feelings.

1. A refusal to accept or believe something, such as a doctrine or belief.
2. Psychology An unconscious defense mechanism characterized by refusal to acknowledge painful realities, thoughts, or feelings.

The act of disowning or disavowing; repudiation.

Abstinence; self-denial. (Dictionary.com)

Definition 3b is the one most people think about when they hear the word "denial". It's a Freudian term which has made it into popular English. It's a pretty self-explanatory term, after all; a person is "in denial" when they refuse to acknowledge the truth of a (usually negative) situation. Denial is necessarily an unconscious defense mechanism; in order to protect the mind from a painful truth, it's pushed aside. Your mind cannot be allowed to consider the truth, whatever it may be, so instead you think "Well, that just can't be true."

It's a term that is far overused, in my opinion, just like many other Freudian terms (Oedipus complex, anyone?) It can be part of the stages of grief, but it tends to be temporary. After all, most of us eventually cave in when we're shown hard evidence of what we fear. A rational person can only deny a situation for so long before the truth becomes indisputable.
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For the past week, I've had a patient in my care who has diffusely metastatic cancer. He's got enough life-threatening issues that he has to stay in the ICU, but there's nothing super-acute. If I had to give my totally accurate, super-informed, expert opinion, I'd give him a few weeks to months to live. His kidneys have failed, but he can get dialysis for that; his gut has failed, but he can get TPN for that; his lungs are stable, and his mind is clear. The dialysis makes him hypotensive, and so do the drugs we give him to cure his arrhythmias, so he's still on pressors. Despite all this, it's not unimaginable that he could leave the ICU, go to rehab, and possibly even home for a brief time. Sadly, this will only be brief. His tumor burden is extensive, and chemo left him without kidneys. It's unlikely that oncologists will resume chemotherapy which was only for palliation after such a dreadful reaction.

One of the hardest parts of seeing my patient every day is having to deal with his wife. Last week, she accused all of us of being totally incompetent, of not communicating with each other at all, and of not doing the things medically necessary for her husband. She accused me of not giving her all the information available when I told her that my team would evaluate the chest x-ray on rounds, and that until then I didn't have an official report to give her. She tries to pin us down on specific times for procedures over which we have no control: "So, in a couple of hours? Then if it's seven now, it'll be done by nine?" Only, after a week in the ICU, she still tries to do these things, even after we've done our best to explain why it might take more or less time to obtain even a simple chest x-ray.

She has accused the oncology team of not explaining her husband's prognosis, even though they have spent hours discussing his disease. She then accused them of hiding from her that chemotherapy can cause immunosuppression and kidney failure, even though the chemo consent form clearly documents these risks. She accused us of not performing dialysis quickly enough over the weekend, even when we explained that he hadn't qualified for dialysis over the weekend. What about drug X, my friend works in a pharmacy and he suggested it? Why didn't you perform this [palliative, symptomatic-only procedure] as soon as he got here, we've been asking for it for WEEKS? Why aren't you feeding him [even though he's vomiting bile and obstructed], he hasn't eaten for so long and oh, you just don't think it's imPORtant?

In turn, she has yelled at and offended all of her nurses, every consulting team, the oncologist, every ICU attending, etc. We never know what we might say that will set her off. All of us have spent great lengths of time explaining things to her in great detail, only for her to fixate on one tiny point and perseverate for the next few days. I dread going to see them every morning, because I can't escape with generalities with her, but I never know what I might say that will make her angry and anxious, or what I might have to spend fifteen minutes retracting. She makes it hard for me to do my job, basically.

Now, I've vented all this from my point of view. To me, this is a woman who is interfering with her husband's care. She is so argumentative and demanding that sometimes, the teams cave in to her and give treatment that we were hesitant to give. She makes her husband anxious. There's a flavor of borderline personality to her; she yelled at my attending yesterday for DARING to suggest that a dialysis catheter be placed in the femoral position, but today she told me how much she preferred the same attending to all the others.

From her point of view, there are tons of doctors coming in and out of her husband's room every day. Sometimes, different doctors and their assistants and the nurses tell her different things, which is confusing to someone with or without a medical background. Her husband can't always speak up for himself, so she has to do it for him.
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There's more to it than this, though. One of the first questions she asked me during our first meeting was "what will this do to his chemo schedule? He was supposed to have chemo this week." In reality, the chemo was only to try to reduce his tumor burden for a little while--there was nothing curative about it, and it really didn't matter when he was to receive his next dose. Her concern, though, was my first clue. After that, I started to figure it out. Every one of these things she fixates on--it's like we're denying him the one crucial treatment which would cure him.

When viewed in terms of denial, her behavior makes much more sense. After all, her husband was only recently diagnosed, but was already at a late stage in his disease. Only a few months ago, there was no cancer. Her future with her husband has been stolen from her, and she is furious. She can be angry with us, because we are the incompetent doctors who aren't doing everything for her husband, and because it's easier to be angry with us than to be angry at him. To be angry at him is to acknowledge that he is dying, which she can't do. She can focus on each medication, routine chest x-ray, lab, etc, because it can be controlled, which the cancer cannot.

Eventually, this facade will crack. As his condition deteriorates, and she becomes more frantic, something will break. We called a counselor to see her (at her request) but she refused to speak with her. I doubt she's spoken to anyone willingly about his diagnosis and prognosis. Eventually, it will all come out. I don't want her to lose all her hope, but I also don't want this moment of revelation to come to her after it's too late.

I am a selfish human being, though, and I just want her to quit bugging me so much and let me take care of her husband. Just because I'm going into psychiatry and can try to understand her situation doesn't mean I don't get frustrated, too.

Where Have All the Blog Posts Gone?

So I keep checking some of my favorite blogs over and over again, because I'm bored, and I'm kinda curious as to why it's been so long since many of these blogs had new posts. Come on, people, what am I supposed to read while I'm not getting interview offers from my #1 school??? I need entertainment, dammit! I DESERVE IT!

Come on, just one little post? Just one? I only need a small one, I swear, just an update on your day or a link description, just a little fix to take the edge off and then I'll be fine...

I'm not really complaining, please don't be offended if you write one of my favorite blogs. It's a compliment to you that I'm so addicted! Really!

Edit: If you write a blog, and you update it a lot, this post doesn't mean you aren't one of my favorites. I promise. I just always seem to need a little more!

Balance

I'm a person who has a tough time with balance. I'm not referring to my klutziness (although I could, because sometimes it's amazing that I walk upright). I'm referring to a kind of balance of life that sometimes I feel like everyone else has besides me.

Medicine is certainly not the only career that promotes a skewed life. One can be a workaholic in nearly any profession or job. Both my husband and I have fathers who work 80+ hour weeks (one as an entrepreneur, one as a CPA). There's something about medicine that encourages total devotion, however, and for those who drink that Kool-Aid, there can be no life outside medicine. Since many doctors are socially retarded (extrapolating from classmates who are certainly not going to acquire better social skills between now and graduation), their lives outside the hospital/clinic are not very rewarding. They learn to base all their satisfaction on medicine, and society condones this. After all, medicine is a "meaningful" profession, so it's only right for you to spend all your time doing it.

In my life, I sometimes feel like I can't possibly do everything I want to do. I want to be a good student/doctor, a good wife, a good daughter and sister, and a good friend. I want to get my body in better physical shape, which requires going to the gym, and I want to take better care of my pets, which involves vet$ and food and the pet $tore and the dog park and boarding, etc. I want to be well-rounded, so I try to go to rock concerts, art museums, the symphony (season tickets this year!), and take vacations. I want to have a clean apartment and be a better, more frequent cook. I want to have beautiful plants in my small garden. I want to express myself on this blog in a meaningful way.

In reality, though, every one thing I try to add knocks another thing out. I get easily overwhelmed by fatigue and then lose all desire to try to cook dinner, so we eat out a LOT (especially on rotations like this one, where I'm physically and emotionally drained). This habit doesn't really help with the physical condition issue, of course, and the fatigue doesn't make it easy for me to go to the gym. I've been going to the gym more regularly for a few weeks, but then I'll have an asthma attack and miss a day or two, which is frustrating. If we go out during the weekend, somehow the apartment doesn't get cleaned, and then I spend the next week disgusted by our living conditions. I've killed almost all my plants. Also, I spend so much time at work dealing with everyone else's problems that sometimes it's hard to listen to my husband talk about his day. After all, I spent MY day HELPing people, for goodness' sake, how could anyone else's day matter?

I think part of the problem is that I try to add too much at once. If I'm not going to the gym every day, then obviously I failed. One reason I let this get me so anxious is that I realize that my life is currently going on, sometimes without me. In medicine, we put everything off for the future: we'll make money later, get married later, have children later, talk to our spouse later, and so on. Since you can't make medical school nicer, you can only make your outside life better (that's my theory). I realize that the point of making your life more well-rounded outside of medicine is NOT to get anxious about it, but hey, that's me. As someone pointed out the other day, "that's TS." If I don't have anything to worry about, who am I?

And who would I be without medicine? I have a gift of intelligence which is, for whatever reason, oddly suited to medicine. I have a repertoire of useless medical trivia that don't help me get pimp questions right, but have totally ruined my ability to win Trivia Pursuit on any other subject. I guess part of what I want is to be able to say that I have an identity other than "future doctor", and part of me worries that I don't.

As for medicine being so meaningful, I'm working on a post to address this issue. If I can work it into my schedule, that is.

The ICU Makes Me Sick

The evening after my last post was entirely uneventful. I made frozen pizza for dinner, my hubby and I watched TV, I blogged, I checked many blogs, and then went to bed. I coughed some, but then I can't really stop coughing. (For some unknown reason, my asthma has turned into "moderate persistent", with daily symptoms, for the past month and a half, despite being "mild intermittent" for years. I can't tell if it's a URI or not, and therefore I don't know if I should fill the Z-pack I was given as an "emergency" script or not.) It really wasn't a special evening.

Until I woke up at midnight and re-experienced the frozen pizza.

After a mostly sleepless night, I called in sick, notifying my nurse practitioner ("the boss"), my attending, my course coordinators, and my course director (all at 5 am--impressive!). Then, I slept till noon.

During my third year of med school, I went to work sick several times. It's something of an expectation that third year med students will not miss work. I did call in "sick" (ie, played hookie) once while on family medicine (and agonized about it for DAYS, I'm terrible at that sort of thing).

As a fourth year, I no longer have any qualms about staying home from work when I'm sick. I called in once last month because of the asthma/URI crud that hasn't gone away (it's been a month and a half!) On this occasion, I wasn't sure if I was done with the ickiness, and I figured that a) I didn't need to be around ICU patients and b) ICU patients didn't need to be around me.

When I went back to work, I felt better, but I still had the sniffles and the cough. Since these were noticeable, everyone assumed that this was why I'd stayed home. Since then, most of my ICU team has come down with some form of cough/sore throat/runny nose/sniffles, and they blame me, despite my frequent hand-washing and obsessive use of hand sanitizer. A friend called me "a walking fomite" today.

Never mind that we're surrounded by patients with every drug-resistant bacterium known to man, I get blamed for the creeping URI. Oh, well.

They All Have Cancer

...and that pretty much sums up my first few days of my required ICU rotation. I'm in a special cancer ICU, on the "solid tumors" team. As one of our PA's said yesterday, we either have "easy" patients--or not. The easy patients are mostly craniotomies for intracranial tumors--ie, brain cancer. They come to the ICU after their surgery, stay overnight, and generally get transferred to the floor the next day. Thus far, I've only managed this kind of patient, as they're not on a ventilator and have fewer serious issues (although I still write a 2 page progress note, detailing labs, meds, and physical exam for every body system + ID & oncology--they're not easy patients yet for me!)

The other kind of patient, according to my PA, come into the ICU from the floor "crazy sick", get a ton of money spent for a 1-2 day ICU stay, then DNR/DNI/withdrawal of care papers are signed and the patient disappears from the list. I believe she (the PA) was talking about what a waste that is.

The "liquid tumors" team (lymphomas, leukemias, bone marrow transplants, etc.) supposedly has a 30+% mortality rate. One of my friends is following a patient with a total bilirubin of 35; his skin is a strange neon green color. Another patient has a strange bacteria I'd never even heard of before--Stenotrophomonas maltophilia--which is apparently resistant to EVERY SINGLE ANTIBIOTIC TESTED EXCEPT BACTRIM. Still another patient has a virulent varicella pneumonia on top of her end-stage metastatic colon cancer.

I could go on and on and on. But I won't. Suffice it to say that it sucks. Yes, I am taking my antidepressant; otherwise, I don't really think I'd make it through this month.

The only thing that could make tomorrow more awesome would be if my nurse practitioner, who introduced herself as "the boss", decided to assign the medical students another learning issue. My 2 minute regurgitation of UpToDate on astrocytoma was spectacular, let me tell you.

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In happier news...

UPDATE ON THE MATCH:
Interview Count: 6
Letters of Reference in ERAS: 1, scanned in today
Letters of Reference NOT in ERAS: 2
First Interview: October 19
Anxiety Level About Lack of Letters: 10 out of 10

The Empowered Patient

Today, CNN.com is featuring an article called "Five commonly misdiagnosed diseases" on their editorial "The Empowered Patient" by Elizabeth Cohen. The article begins with a large picture of John Ritter, mentioning that he died of an aortic dissection; his family later won a malpractice suit alleging that he was misdiagnosed "at least twice." She alleges that "certain diseases are misdiagnosed over and over again. It's worth knowing what they are so you won't be a victim."

The five diseases mentioned: aortic dissection, cancer, coronary artery disease, acute MI, and infection. Three of these (cancer, MI, and infection) are from a study at Harvard by Gandhi TK, et al regarding settled malpractice claims in the outpatient setting (Ann Intern Med. 2006;145:488-496.)

The solution, or "how can you keep yourself from becoming a victim of misdiagnosis?" Here are the five ways given to protect yourself: "Ask for more tests", "Ask 'what else could my illness be?'", "Don't assume no news is good news", "Assume your doctors don't talk to one another", and "Be wary when your doctors work in shifts".

I'll just throw this out here now: I greatly dislike this column. There is a little defensiveness on my part, I'll admit it; doctors do make mistakes, every day, but I don't like the tone of some of the articles. However, let's examine her evidence a bit, and I'll see if I can't give you a reason to question this article as well.

Issues I have with this article:

1) John Ritter: His family did indeed sue the hospital (successfully) for "missed diagnosis". Cases against three doctors are still pending until 2008. Even though he was apparently in emergency surgery within 4 hours of arrival at the ED, he died on the table. See Rangel MD's post on why he thinks the ER docs followed all the right steps, and why the "misdiagnoses" were appropriate steps along the pathway to the correct diagnosis. If you really want a blatantly misdiagnosed aortic dissection, look at Jonathan Larson (author of Rent); he was sent home from two ER's with "flu" or "stress" and died suddenly at his apartment.

2) Aortic dissection in general: For a proximal aortic (acute) dissection, 40% die immediately. Within 24 hours, 70% die. If left untreated, the condition is eventually 100% fatal (or close enough). A proximal dissection is a surgical emergency; if treated, there is a 70% 3-year survival rate. Distal dissection is better managed medically, as the surgical mortality is high. Interestingly, "Overall survival rates at ten years are approximately 5% for untreated patients and 50% for treated patients (49). Operative mortality has decreased to about 20% (57)." (Auer J, et al). In other words, 20% of patients still die in surgery, and 50% of the patients still don't make it 10 years even with good treatment. This is a big, bad disease.

Misdiagnosis is only going to make this worse, of course, because delaying surgery in an acute proximal dissection (Stanford A/Debakey I-II) can be fatal. Unfortunately, a chest X-ray has only 67% sensitivity and low specificity, because a wide mediastinum could be caused by many things. The test of choice is CT angiography, which takes a little longer and requires IV contrast, but has a sensitivity/specificity of 96-100% (See Wikipedia article). In this case, one of the things Ritter's widow alleges is a "simple X-ray" would have given the diagnosis; this is not entirely true.

Moral of the story? Misdiagnosing an (acute proximal) aortic dissection is almost certainly a death sentence, especially if treatment is delayed for days. However, if 4 hours was too long for Mr. Ritter, then I'm not sure he could have been saved (and that's my personal opinion--things take a while in the ER, doing the ABC's and getting the EKG and the chest x-ray and the CTA and calling the OR and the cardiothoracic surgeons and getting an unstable patient to surgery, etc. This stuff takes time. I don't know whether this 4 hours is below the available standard of care at that hospital. In other words, I don't know whether this constitutes a breach of care or not.)

3) Coronary artery disease: "Sometimes doctors tell patients they're short of breath because they're out of shape, when it's actually coronary artery disease, says Bonow, who's also the chief of cardiology at Northwestern Medical School." This quote is meaningless because a) If you interviewed a pulmonologist instead of a cardiologist, he'd have told you that shortness of breath could be an undiagnosed PE. Pick your specialist, pick your disease and b) There's no references (besides Dr. Bonow) or studies here, so I can't really say how often this occurs.

Basically, you diagnose CAD by visualization at angiography or after the patient has had acute coronary syndrome (angina, MI, etc.). There's no one great screening test for CAD. We approximate by checking risk factors: family history, smoking, cholesterol profile, blood pressure, and diabetes are the biggest ones (of course, there are others). In a patient who fits the picture, we may offer stress testing or other measures. Sadly, not all patients fit the stereotype, and I'd imagine it's a younger, fit person who presents atypically who would be misdiagnosed more frequently (this is just my guess). Patients with no/few risk factors may still have CAD.

While I do think it's negligent to just tell a patient "you're just out of shape" without doing any kind of exam or workup, I could see how a patient might fall through the cracks here. I couldn't find any studies to say how often CAD was misdiagnosed (and I'm referring to asymptomatic CAD, not acute coronary syndrome).

4) "Demand more tests." The example they gave here, of the RN whose endometrial cancer was misdiagnosed for 3 years as "menopause", is probably the one example in the article where if I were that patient, I might have sued. Then again, if I were that worried, I'd have gone to another doctor. Heavy bleeding in a perimenopausal woman should be ruled out for endometrial carcinoma, period (ha!). I'm not sure the "simple ultrasound" she mentions would have done the job (although it can be used as a screening test by the thickness of the endometrial stripe or by ruling out fibroids) but she warranted an endometrial biopsy. If her doctor didn't at least recommend one, he/she was negligent, IMHO.

However, more testing isn't always going to solve your problem. While failure to order a diagnostic test was the most common reason a diagnosis was missed in the Harvard study (55% of the errors studied), that means 45% of the errors were made even with the appropriate testing. Additionally, errors in the testing itself were also common; just because a test is ordered doesn't mean it will be performed or interpreted correctly.

5) "Be wary when your doctors work in shifts." Up until now, the article has mostly dealt with outpatient issues. The Harvard article (which wasn't actually cited, I had to search by "malpractice claims" in PubMed to find it) deals only with outpatient mistakes. Doctors who work shifts are typically inpatient. The article cited here, "Fumbled Handoffs", is a case study by the same Dr. TK Gandhi from Harvard ( Ann Intern Med. 2005;142:352-8.). The error she attributes to "multiple handoffs", however, actually comes from a human error (a wrongful interpretation of a chest x-ray as "normal", written on the chart) which was given in handoff with the patient. She then describes a "diffusion of responsibility" associated with multiple handoffs, ie the receiving resident should have read the chest x-ray himself. I don't think that's an error of the handoff policy, but rather of the resident believing the night float resident's documentation in the chart. Basically, he should have looked it up himself, whether the person speaking to him was the night radiology resident or the float resident. To me, this error had nothing (or little) to do with the float system.

Through a documented series of MULTIPLE errors, in this case study, an elderly man died of TB after his diagnosis was missed on several occasions. Certainly, medical handoff policies can contribute to errors. Here's an abstract of a policy on how to reduce errors with handoffs.

I think it's misleading to include this information in this particular editorial, because a) other data in the article is outpatient, not inpatient; many people reading the article may not understand this distinction, especially since the 2006 study is not actually referenced properly and b) I disagree with Gandhi's emphasis on the multiple handoffs in this patient's misdiagnosis in the case study. I'm not denying that this type of error can occur, but I think a different study would have served better to illustrate it.

Also, as Gandhi points out, studies have shown that "traditional" medical shifts with overnight call also cause error. Look at Landrigan et al, NEJM 2004;351:1838-1848 for this study of ICU residents working q3 call shifts compared to a reduced schedule of 63 hours/week with no overnight calls; the interns working fewer hours made 35.9% fewer "serious medical errors". My concern is that if we don't clean up the errors in the handoff process, we'll all be working q3 again, which isn't really good for anyone, is it?

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Here's my guide to being an empowered patient:

1) Ask your doctor questions. It's his/her job to answer them, even if they're dumb questions.

2) If you disagree with your doctor, and you can't get an answer you think is reasonable, get a second opinion.

3) If you look stuff up on the internet, use something like WebMD or eMedicine. Do not go to Cletus' Sight on Awtism and the Vaccine Devil!, because *gasp*, you won't get balanced information there.

Doctors DO make mistakes, every single day. They can be serious. Inform yourself and ask tons of questions, and if you think a mistake is being made, speak up.