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The CMG Voice

The community decides what the standard of care in medicine is.

Posted Thursday, November 2, 2017 by Tyler Goldberg-Hoss

Every time I consider a potential new medical negligence case, or think about a case I am currently handling, it is in the context of how I think community members – jurors – will think about the care in question. The reason is, if I file a lawsuit on behalf of a client of mine, the end result will likely be a trial in front of 12 men and women in the county where care occurred.

The first question a jury will likely decide in such a case is whether the health care provider in question met, or fell below, the “standard of care.” This “standard of care”, in essence, is the health care provider’s duty to his or her patient to act reasonably carefully in caring for the patient. If the doctor met the standard of care, she is not negligent. If she fell below the standard of care, she is.

So how does a jury know what the “standard of care” is in a given situation?

Sometimes, it’s obvious. Sometimes the care is bad enough, and both sides know it. In those situations, the cases typically settle out of court.

Often times, though, there is not a particular authoritative text you can point to and say that a doctor or other healthcare provider clearly broke a particular rule.

In those situations, each side hires experts – physicians who practice in similar circumstances as the doctor who provided the care in question – who testify in court about what the “standard of care” is, and whether or not it was met this time. The jury listens to the experts, then deliberates and decides whether they agree with the experts for the patient or for the doctor.

This is an important point. To even get in front of a jury, the patient must offer sufficient expert testimony that the defendant doctor was negligent. However, once that threshold is met, the jury gets to listen to the testimony, and they get to make their own decision. That decision should not be made based on sympathy or bias, but it necessarily must be made on what the jury believes was the “standard of care” in the situation before them, and therefore what it should be in the community going forward.

You see, in Washington, the doctors don’t decide what the “standard of care” is, nor is the standard based on what care is expected by other doctors. It is decided based on what is expected by society – us, the community, and the representatives of it who sit on the jury.

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Early detection and treatment of melanoma critical for survival

Posted Monday, October 30, 2017 by Tyler Goldberg-Hoss

The results of a recent Cleveland Clinic study make clearer than ever that the sooner melanoma is detected and treated, the better.

Melanoma is the deadliest form of skin cancer. Rates of the disease are on the rise in the US, as an estimated 161,790 new cases will be diagnosed this year.

Previously, it was understood in the medical community that early detection is important to surviving melanoma. However, this recent study actually quantifies how much early detection can affect survival rates, particularly with respect to melanoma caught at Stage I.

The study looked at adult patients diagnosed with stage I-III melanoma from 2004-2012. It found, among other things, that the delay in surgery beyond 29 days negatively impacted overall survival for patients with stage I melanoma. Compared with those patients who were surgically treated within 30 days, those patients treated between 30-59 days were 5% more likely to die. Patients treated between 60-89 days were 16% more likely to die, patients treated between 91 and 120 days were 29% more likely to die, and when treated after 120 days, they were 41% more likely to die.

These findings are stark reminders that prompt diagnosis and surgical treatment can make the difference between surviving the disease and not. This includes so many front line providers, including family practice physicians, PAs and ARNPs fulfilling similar roles, as well as dermatologists, surgeons, oncologists, and others.

You can read a synopsis of the new study from the Cleveland Clinic itself here:

Cleveland Clinic Study: Timing of Melanoma Diagnosis, Treatment Critical to Survival

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Insurance rates play a big role in the difference in diagnosis and prognosis of breast cancer in black versus white women

Posted Thursday, October 26, 2017 by Tyler Goldberg-Hoss

The results of a recent study found that non-elderly black women were at greater risk of dying from breast cancer than non-elderly white women. One important reason was the racial disparities in insurance coverage.

The study, published in the Journal of Clinical Oncology, looked at white and black women ages 18-64 who were diagnosed with breast cancer between 2004 and 2013. The results show that four factors contributed to a significant increase in risk of death in black women versus white women: comorbidities, insurance, tumor characteristics, and treatment.

These factors accounted for 76.3% of the total excess risk of death in black women. Differences in insurance accounted for 37% of the total, nearly half of the disparity and by far the biggest single reason that black women were more likely to have larger and more serious tumors at the time of diagnosis.

With regard to the insurance coverage, black women were much more likely to be uninsured or insured through Medicaid than white women.

You can read the entire study here:

Factors That Contributed to Black-White Disparities in Survival Among Nonelderly Women With Breast Cancer Between 2004 and 2013

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Is a hospital negligent for not having your blood type when you need a blood transfusion?

Posted Monday, October 23, 2017 by Tyler Goldberg-Hoss

Consider a situation where a patient is in the hospital and has surgery. During the surgery there is a complication, resulting in increased bleeding and the need for a transfusion. There is just one problem: the hospital doesn’t have the right blood type to match to the patient. What can be done? Is a hospital legally responsible for any harm that occurs as a result of this lack of blood?

To begin, there are four major blood groups: A, B, AB and O. In each of these groups, the presence of an Rh factor determines if a person is + or -. So there are 8 different blood types all together.

Depending on your blood type, you can accept transfusions safely from other blood types, and other people can accept your blood type safely. For example, if you have Group O blood, you can donate to any other blood group. However, if you have Group AB blood, you can only donate to another person with AB blood.

Further, if you have Rh-negative blood type, you can donate your blood to patients who are either Rh-positive or negative. If you are Rh-positive, you can generally only donate to Rh-positive folks.

Here is a handy chart from the American Red Cross that shows this:

Alternative Text

In the United States, hospitals and other health care providers who are responsible for providing blood products to patients must rely on donations of blood. There are Blood Banks where you can go and donate blood, and often there are blood drives set up where mobile buses park and people can donate.

Given that supplies are made by donation only, it can be difficult for hospitals to always have enough blood on hand to handle any possible situation.

So back to the hypothetical above. Certainly, it is possible that the hospital failed to follow its own policies and procedures regarding having blood products on hand. Perhaps it failed to have a system in place for alerting staff when levels were low so they could initiate a plan to receive more. Or perhaps staff knew or should have known of the low levels of blood on hand, and decided surgeries should be done somewhere with more blood available in case of an emergency.

And, it is also possible that there is just not enough blood around the area for the hospital to have enough. In such a situation, and because the hospital is at the mercy of the general public donating blood, it is difficult to find fault.

And the doctors in those situations are between a rock and a hard place. On one hand, the patient may die without a transfusion. On the other, there are risks to giving a patient a blood type that is different than their own. In particular, the patient may suffer an ABO incompatibility reaction, which results in the immune system producing antibodies against the incompatible blood. This can be life threatening itself.

Of course, there are times when the wrong blood is given in a hospital because the blood is mislabeled, or some other human error occurred. In such situations, the hospital may be legally responsible for the harms caused. However, there are other circumstances that are out of a hospital’s control. Until we as a society improve the supply of blood products, there will continue to be instances where a patient needs blood, and the hospital doesn’t have it.

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Does Chronic Pain Amplify The Pain From New Injuries?

Posted Thursday, October 19, 2017 by Gene Moen

A recent study presented at the American Pain Society annual meeting, shows that if you have chronic pain in one body part, your brain’s reaction to pain in another body part is intensified. The reason is that chronic pain tends to re-wire circuits in the brain region (anterior cingulate cortex or ACC) that regulates how the brain reacts to pain.

Prior studies emphasized “nociception,” which is the sensory nervous system’s response to certain harmful or potentially harmful stimuli. But nociception focuses on the signals from, for example, a burned finger, not on how the brain reacts or deals with the signals once they arrive.

The study arose from clinician’s observation that when patients had chronic back pain they often reported higher than normal paid after surgery in the knee or abdomen. According to Dr. Jing Wang, one of the researchers, “our study results argue that chronic pain causes distortion in how the ACC calculates pain intensity with system-wide consequences.”

In past research, it has been shown that a body part that produces chronic pain can trigger magnified pain when the same part is injured again. But the new study, for the first time, shows that chronic pain tends to increase the reaction to pain-causing stimuli throughout the body. The study authors used rats to study how chronic pain dramatically altered ACC activity. Interestingly, the study results also implied that chronic pain can magnify responses to light (e.g., in migraines) and the ACC can be involved in emotional processes. Thus, anxiety and depression may also amplify the brain’s reaction to painful stimuli.

Focusing on the ACC region of the brain may allow new technologies, like deep brain stimulation and transcranial magnetic stimulation, to deliver electric current to reverse nerve cell signaling patterns that can cause disease.

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