three dot medicine

Saturday, June 24, 2017

Time for three dot medical journalism, with a nod of respect to Herb Caen.

Fractures...Just because you can move it, doesn’t mean that it isn’t broken. All it means is that the muscles and tendons surrounding an injured bone still work…If you thought that a normal x-ray means that the bone is okay, think again. In some circumstances, regular x-rays miss significant breaks and CT or MRI are needed if the clinical suspicion of a fracture is high…And by the way, fractured, broken and cracked all mean the same thing.

Strep…People equate a sore throat and strep infection…Most sore throats are caused by a virus and do not need antibiotics…When an antibiotic is prescribed for strep, it is not to make the throat feel better faster…Once upon a time, untreated strep throat could lead to rheumatic fever and then rheumatic heart disease, an inflammation of the heart valves…Now, rheumatic fever is so rare in the US that the Centers for Disease Control and Prevention don’t require it to be reported…There is an exception for children of Samoan or Fijian descent who live in Hawaii have an increased predisposition to post strep heart disease.

Narcotics...The downside to the national opioid prescription crisis…If you wonder why it might be taking longer to get your narcotic pain prescription written… many states now require providers to log onto controlled substance registries to check how often and how many prescriptions have been filled in the recent past…The goal is to limit the abuse of narcotics and sedatives but it also makes patients wait…Some of the websites can be more than a little slow.

Drug interactions...Summer is the time to travel and included in the packing list should be an update list of medications including names and dosage…Having just returned from giving a talk in Pinehurst NC, a mecca for golf vacationers, I had an earful from local docs whose ability to care for patients is hamstrung by a lack of information…Many medications, including antibiotics can interact with each other causing problems… Remember that herbal and over the counter medications count.

Wound infections...Summer is also the time to hang out on the water…Cuts and scrapes will happen but it’s important to avoid the reflex of washing them in the natural water…What was a simple laceration that could be sutured can be turned into a complicated mess if the wound was dunked into a river…Each region of the country has its own bad bacteria and the “do no harm” caveat holds especially true when it comes to sewing up wounds.

Watching…And for those who wonder why medical care takes so long to happen…A reminder that on television, most medical dramas have 40-45 minutes of action, 15 minutes of more of commercials and a minute tease for the next episode…in the real world, going straight to a high tech test or treatment may not be appropriate…Sometimes, time is an important part of the diagnosis and observation may be the way to go…Watching  what happens to a patient over time may not make great television but it may make great medicine.



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narcotics role is changing

Monday, August 29, 2016

Football is a violent sport and with it comes injury and that begets pain. Some injuries are self-evident, like the tibia and fibula fracture sustained by Chicago Bears quarterback, Connor Shaw. His leg was splinted and he was carted off the field in obvious pain. Other injuries take some time to sort out, like the Cowboys’ Tony Romo, who failed to talk his way into playing in the same game and was later found to have a compression fracture of his lumbar spine. Both injuries hurt and both players will likely be prescribed narcotic pain medication in the first few days of recovery. NFL players have been known to take a variety of legal and illicit medications to allow them to play through the pain each weekend, but that mindset does not translate well into the real world off the playing field.

The Fifth Vital Sign

Not too long ago, pain was added to the medical mind frame as the fifth vital sign. It followed blood pressure, pulse respiratory rate and temperature. Regardless of the reason for the doctor’s visit, patients were often asked whether they were having pain and their assessment, often on a scale of zero to ten. Kids had the smiley/ frowny face pain scale option. Pain is not normal and medicine is all about keeping vital signs in their normal range. Patients didn’t want to hurt and it was easy for a doctor to write a prescription for narcotics.

Doctors like to make their patients feel better but there was another benefit to writing the prescription. Patient satisfaction scores for doctor performance might have been tied to giving patients what they want. Who knew that excessive narcotic prescribing habits might lead to an increase in drug dependence, addiction and become a gateway to the increase abuse of heroin and other illegal street drugs.

The pendulum is beginning to swing back and patients might take a while to understand that a pain-free life may not be available through the use of narcotics. They may not like the doctor who says no to their request and those negative feelings are being expressed by examples of falling patient satisfaction scores.

Wisconsin Prescribing Guidelines

The Wisconsin Medical Examining Board, the governing agency that licenses doctors in the state) has published guidelines about prescribing narcotics, including when to use them what drug to prescribe, how many pills and the expectation to look for patients who exhibit drug seeking behavior. Doctors in the state need to listen and act according. Without a medical license, their career has effectively ended. Just a few of the highlights:

  • It is difficult to know how much a patient hurts. Find out why there is pain and treat the underlying cause. Use non-opioid (non-narcotic) medicines like acetaminophen, ibuprofen or naproxen.
  • If prescribing narcotics, use the lowest dose and fewest number of pills. Most patients will need less than three days of treatment and rarely more than five.
  • There is little evidence that narcotics should be used to treat chronic pain.
  • “Physicians should avoid using intravenous or intramuscular opioid injections for patients with exacerbations of chronic non-cancer pain in the emergency department or urgent care setting.
  • Physicians are encouraged to check Wisconsin Prescription Drug Monitoring Program website to see whether the patient is already receiving narcotics from other doctors. This becomes law in April, 2017 before prescribing any controlled substance for greater than a three-day supply.
  • “The use of oxycodone is discouraged.”

Patient Satisfaction

Patients may not be satisfied with the result of their doctor visit if expectations for pain control are not met. This might be especially true for chronic pain patients who have come to rely on narcotics for their symptom control. It may take time to consider treatment alternatives and still meet the needs and demands of the patient.

The New York Times reported on the experience at Marion (Indiana) General Hospital. Over the course of 18 months, emergency physicians decreased their narcotic prescribing by 50%. Patients weren’t happy and ER satisfaction scores fell from the 58th percentile (of 1100 similar hospitals) to the 14th. Does that mean that the doctors practiced bad medicine or did it mean that there was a disconnect between what the patient wanted and what they received. The words of Mick Jagger and Keith Richards might have been ahead of their time describing this phenomenon.

You can’t always get what you want…you get what you need.






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