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The CMG Voice

No Single Solution to America’s Abysmal Maternal Mortality Rates

Posted Friday, June 7, 2019 by Carl-Erich Kruse

Readers of this blog may have read prior coverage of maternal mortality rates in the United States. The Centers for Disease Control recently released the results of a multi-year study of pregnancy related maternal deaths in the United States. Over the course of the study period, 2011-2017, about 700 women died per year in the United States from childbirth related complications. A break down of the results paints a distressing picture for expectant mothers and their loved ones.

The CDC found that some sixty percent of these deaths were preventable with proper medical care.

Additionally, African-American and Native women died at a rate 3.3 and 2.5 times that of white women. Why these extreme disparities exist is the subject of further research and coverage, but one theory regards the quality of care available to different communities in the United States.

Why are some four hundred women dying each year from preventable complications? Why, frankly, may be too big a question to tackle. In each specific case that was preventable, though, there was miscommunication, omission, lack of sufficient access, or overlooking warning signs. The CDC report suggested that reducing the rate of pregnancy related deaths has to be a multi-pronged approach by “reviewing and learning from each death, improving women’s health, and reducing social inequities across the life span, as well as ensuring quality care for pregnant and postpartum women.” Some suggestions included patients and providers working together to best manage chronic health conditions and standardizing approaches to handling obstetrics emergencies.

The process of improving healthcare for expectant mothers is an ongoing and evolving process. Reports like this one, from the CDC no less, serve to provide background for systemic improvements to patient care by raising discreet issues of public interest. There is no silver bullet to improving outcomes for these patients, and change is slow, but studies like this demonstrate that change must happen. The test now is: how does the healthcare system, how to OBs, how do facilities, improve their systems, how do we provide more care to expectant mothers so that we may reduce our maternal mortality rates to be consistent with the rest of the developed world?

Of the many possible answers, bringing meritorious civil suits alleging wrongful death are a useful way to effect change. When community members form a jury and decide what the standards should be in such circumstances, there will be a future deterrent effect, and all of us will be safer.

Read the CDC report here.

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Medical Bills that can Bite

Posted Thursday, May 30, 2019 by Carl-Erich Kruse

It’s a parents worst nightmare (part 1): Josh Perry and Shelli Yoder received a call in the middle of the night that their daughter, away at summer camp, had been bitten by a copperhead snake. She was being transported via air ambulance to a hospital from the remote wooded location. Josh and Shelli launched out of bed to race her to the hospital.

It’s a parents worst nightmare (part 2): Josh and Perry received medical bills some weeks later for their daughter’s treatment: $142,938.

The bill was not for a lengthy hospital stay, not for dozens of medication administrations, not for interventional procedures. The air ambulance was $55,577.64; the Emergency Room was $3,851. Amazingly, the antivenin, four vials worth, cost $67,957. That’s $16,989.25 per vial.

How did it get to cost so much? And who bears this cost?

Kaiser Health News reports that the manufacturer of this antivenin has a virtual monopoly in the US. The manufacturer, CroFab, charges $3,198 per vial. Some of you have already figured out that is a $13,791.25 difference. A portion of the cost was then negotiated down by the family’s health insurance, which paid $107,863.33. Although the family did not pay anything out of pocket, these often extravagant costs for medication frequently end being absorbed by rising premiums or by Medicare/Medicaid. In effect, we all pay.

Efforts are under way to manage health care costs. Recent federal law requires hospitals to post prices online. Perhaps coincidentally, the hospital in this story now charges $5,096.76 for this antivenin. Competition may be helping too: other antivenin products are arriving on the market for approximately 1/3 of the price.

As multiple efforts grow and evolve to manage drug prices, stories like these will (hopefully) become less commonplace.

Read the Kaiser Health News article here.

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Feres Doctrine Anything but Fair to Servicemembers

Posted Monday, May 27, 2019 by Tyler Goldberg-Hoss

On this Memorial Day, it is obvious that we take time to remember and honor those men and women who have died while protecting our country.

It is also a good time to reflect on a law which continues to single out these same men and women for unfair treatment when they are injured as a result of the negligence of other enlisted personnel. This law is called the Feres Doctrine, and it needs to be changed.

The Doctrine was created in part to avoid litigating military decisions in civilian courts. However, in practice it prevents much more than that. In the context of medical care, it prevents patients from bringing claims of medical negligence involving care at Naval Hospitals such as the one in Bremerton.

We have written about the Feres Doctrine nearly three years ago in the context of the case of Rebekah Daniel.

Ms. Daniel was active duty when she delivered a healthy daughter at the Naval Hospital. Unfortunately, doctors allegedly failed to stop her from bleeding, and she died.

A local attorney attempted to bring her claim, knowing the odds were long because success would mean changing this long-standing rule. Recently, the Supreme Court denied the family’s petition to have her case heard.

This case has nothing to do with allowing a Court to determine whether some military decision in the field of battle negligently caused a servicewoman to die. It has to do with allegations of medical negligence causing Ms. Daniel her life. If she were not enlisted, her family could have brought her claim on behalf of her surviving husband and daughter. That would have allowed for the court system to properly weigh the allegations, and if negligence was committed, to properly compensate the family for the terrible harm it caused.

This would have further acted as a deterrent for future care at the Naval Hospital, hopefully contributing to a safer hospital and society for all of us.

But because of the Feres Doctrine, none of that will happen.

You can read more about the history of this legal case, what justices may have been willing to scrap the Doctrine, and other ways the rule may be changed here:

U.S. Supreme Court declines to hear medical malpractice case for death at Bremerton military hospital

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Fungus Prompts Closures of ORs at Seattle Children’s Hospital

Posted Wednesday, May 22, 2019 by Tyler Goldberg-Hoss

Aspergillus is a common fungus that is all around us, including the air we breathe. For most of us, it causes no issues. However, it can be problematic, deadly even, if it finds its way into the wrong part of the body, and/or into a patient whose immune system is not strong.

That is what makes the recent discovery of aspergillus in the operating rooms at Seattle Children’s Hospital so worrisome, particularly for the pediatric patients and their families.

Some people, particularly those who may be patients at Seattle Children’s, have depressed immune systems. For those people, even breathing in Aspergillus can cause serious infections.

For others, even if they are not immunocompromised, if they have a surgery and the Aspergillus gets into their surgical site – the knee or brain, for example – that can also cause a serious, sometimes deadly infection.

So for operating rooms such as those at Seattle Children’s, it is vitally important that the air is free from Aspergillus and other things that can get into a patient’s surgical site and cause infections.

Environmental engineers at Seattle Children’s continue to evaluate the airflow in and around the ORs, in hopes of identifying the reason for these increased levels of the fungus.

Meanwhile, surgical patients are either being moved to outside facilities for surgeries, or having their surgeries postponed. For the hospital and its patients, it’s an unfortunate situation to be in. On the one hand, no one wants patients to develop unnecessary surgical site infections. And on the other, some of the patients really need surgery, and sending them to outside hospitals such as Harborview can disrupt the continuity of care for a pediatric surgical patient.

It is a difficult situation, most of all for any patients who develop a serious infection as a result.

You can read more about this here.

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Sleep Aids now Must Carry Warnings of Risky Sleep Behaviors

Posted Tuesday, May 21, 2019 by Carl-Erich Kruse

The FDA this week announced that it is requiring certain sleep aids to prominently feature, on their boxes, warnings of risky sleep behaviors such as sleep walking and sleep driving. The warning is meant to warn patients to stop taking the medication if they are finding they are engaging in activities when they are not fully awake. The FDA warning is targeting popular sleep aids Lunesta, Sonata, and Ambien.

The FDA acknowledges that the Boxed Warning is the agency’s most prominent warning, and the Contraindication is the agency’s strongest warning, to avoid use in patients with prior episodes of complex sleep behavior. These behaviors can lead to injuries and death of either the patient or victim of the half-asleep, unaware patient. The warnings are meant to inform both patients and health care professionals.

The drugs have been on the market to treat insomnia or many years. Injuries from complex sleep behaviors are rare, but can be significant and devastating, hence the warnings. These warnings are in addition to previous ones that the medication can impair driving and activities that require alertness the morning after use. Drowsiness has already been listed as a possible side effect.

You can read the FDA press release here

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