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The CMG Voice

A Reminder Of The Value Of Checklists In Medicine

Posted Thursday, October 4, 2018 by Gene Moen

A family member recently attended a “fear of flying” program at SeaTac Airport. She and the other participants met with pilots and other professionals and even visited the air traffic tower and spent some time on the flight deck of an airplane. She was very reassured about the safety procedures that were followed by almost all the members of the “flight team.” She commented about how extensive and exhaustive were the checklists used by the pilots before they took off on a flight and how this avoided the risk of missing some crucial step in getting ready to fly.

It made me think of a recent article I read about the use of checklists when, in a long surgery, a new anesthesiologist takes over anesthesia services. Studies have shown that this kind of “hand-off” can create risks to patient safety. One study showed that there was a combined 14% increase in mortality, hospital re-admission, and major complications occurring within 30 days after an operation in which there was a change of anesthesiologists.

Experts studying this problem felt that the hand-off could be viewed as an opportunity to correct errors if there was the use of a checklist at the time the care is transferred. They concluded that this “might prevent an inadvertent oversight of a required action and resultant patient harm.” Having familiar and standardized communications techniques and tools, such as checklists, can make the hand-off a means of assuring continued good anesthesia care.

A few years ago Dr. Atul Gawande, a surgeon, wrote a book entitled “The Checklist Manifesto.” One reviewer of the book commented that “the routine tasks of surgeons have now become so incredibly complicated that mistakes of one kind or another are virtually inevitable: it’s just too easy for an otherwise competent doctor to miss a step, or forget to ask a key question or, in the stress and pressure of the moment, to fail to plan properly for every eventuality.”

Gawande then visits with pilots and the people who build skyscrapers and comes back with a solution. Professionals, including doctors, need to use more checklists. Note that the pilot checklist that impressed my family member was a partial source of the idea of using such checklists in medicine as well as flight.

In Dr. Gawande’s book, he notes that a secondary advantage of mandating checklists in the surgical setting is that it empowers the non-physician members of the operative team to intervene when a surgeon is rushing into the operation or avoiding some of the steps in the checklist that should be taken. The importance of this was highlighted when the Washington Medical Quality Assurance Commission recently suspended the license of a high-powered neurosurgeon because he had an anger-control problem and would berate other health care providers when they would question what he was doing.

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New case report finds chiropractic adjustments can cause vision problems

Posted Wednesday, October 3, 2018 by Tyler Goldberg-Hoss

The American Chiropractic Association reports that there are over 75,000 chiropractors in the US treating over 35,000,000 Americans every year.

Presumably, most of those visits do not result in negative health consequences. However, occasionally patients are harmed by chiropractic care, just as with other treatment modalities.

It has been known for some time, for example, that “high-velocity, low-amplitude” (HVLA) cervical (neck) manipulation can cause arterial dissections, which can lead to serious consequences such as stroke or death if not timely diagnosed and treated.

However, a new case report published by the American Journal of Ophthalmology found a connection between HVLA manipulation and damage in the eye, specifically the retina.

The report notes that the adjustment can cause not only indirect harm to the eye by occluding an artery providing blood to the retina, but can also more directly damage the eye. This can occur both with bleeding in the eye, as well as “posterior vitreous detachment”, where the manipulation causes the vitreous humor (the jellylike tissue filing the eyeball behind the lens) detaches from the retina.

Of course, complications such as dissection or vision problems are unusual. Still, this report supports the position held by many health care related associations that HVLA neck manipulations are not risk free, and carry small but known risks of potentially catastrophic consequences.

You can read the full article here:

Preretinal hemorrhages following chiropractor neck manipulation

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Will the Apple Watch heart-monitoring app make you healthier?

Posted Monday, September 17, 2018 by Tyler Goldberg-Hoss

Recently Apple came out with a new feature for its Watch – a heart monitoring application that can accurately detect a person’s irregular heart rhythm, among other things. In fact, Apple sought and received FDA approval as a “Class 2 Medical Device”. Such a rhythm, called atrial fibrillation or “a-fib”, can have serious health consequences, increasing the risk of stroke and heart failure.

Certainly, finding undiagnosed a-fib can be a good thing – leading to simple, non-invasive treatment (typically blood thinning medication) that may avoid catastrophic consequences. However, problems can arise if the app “catches” an irregular heart rhythm, yet it is a false positive: it says you have it when you don’t.

It can also signal other potential red flags for users who, without any medical training, may incorrectly interpret the results. For example, a long distance runner will be prone to lower heart rates (bradycardia). This isn’t necessarily a bad thing, yet inexperienced wearers may be sufficiently alarmed to seek medical attention.

These and other unintended consequences have the potential to increase the number of visits to health care providers by Apple Watch wearers concerned about non-existent medical conditions. And those same doctors may be in for a “data dump” – patients sending in EKG readings over and over again.

This increases the load on the medical system, and may further result in unnecessary testing, some of which may carry risks. Further, from a medical negligence standpoint, what duty arises on the part of the health care provider whose patient sends in EKG data from his or her watch? If the EKG is one of dozens sent in, and shows an undiagnosed irregularity, and the patient goes on to suffer a stroke, what then?

Certainly this new application shows promise. It does however come with the possible for unintended, and negative, consequences. More data is needed before coming to any definitive conclusions, at least in the form of how these Watches are used in the context of health care.

In particular, one would hope as more and more gadgets are used to monitor vital signs, that health care institutions and organizations governing health care develop reasonable guidelines for accepting, analyzing, and using such data in the future.

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Heart Failure Medications Under Prescribed

Posted Wednesday, September 12, 2018 by Morgan Cartwright

About 5.7 million people in the U.S. have heart failure according to a 2016 report by the American Heart Association. About half of these people have a condition called reduced ejection fraction, which is a weak heart muscle that does not eject the normal amount of blood in each heartbeat.

Heart failure results in a lower quality of life and frequent hospitalization, as well as 300,000 deaths a year. However, in some large clinical studies, certain medications have shown to help people with heart failure and reduced ejection fraction live longer and better lives. The American College of Cardiology, American Heart Association, and Heart Failure Society have put out guidelines on these medications to direct doctors.

A new study of 3,518 patients and 150 primary care and cardiology practices by UCLA looked into the patient prescriptions of three different heart failure medications. Unfortunately it was found that 27 percent to 67 percent of patients were not prescribed the recommended drugs.

Even when they were prescribed the drugs, many were given lower-than-recommended doses. Less than 25 percent of patients received all three-medication types, and only 1 percent received the target doses of all three medications.

The results suggest that use and dosing of heart failure medications has not improved over the past decade. New strategies are needed to help get patients the needed medications. This would help improve the care and outcomes for people with heart failure, leading to better quality of life.

You can read more here:

Drugs for heart failure are still under-prescribed, years after initial study

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Patients Fear Interns, Interns Fear Patients

Posted Friday, September 7, 2018 by Morgan Cartwright

In the early summer months, medical students start taking on new internships in medical centers. Interns have historically been afraid of patients because of the new situations they encounter. Without repeat experiences of these situations, the knowledge from medical school can be lost in the emergent issues of the patient.

In a recent study by Accreditation Council for Graduate Medical Education (ACGME), they examined patient’s feelings towards new interns who provided their care. The majority of patients were uneasy, which increased when the interns themselves were uneasy. To remedy the problem, patients and interns unanimously wanted a “confident, knowledgeable supervising doctor”.

This study presents an interesting problem in the medical field and patient care in general. There needs to be a balance between intern experience and doctors helping teach the interns. Without that, interns may not diagnose or treat patients correctly, which can put patients at risk.

New Report: Patients & July Interns Equally Frightened by One Another

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