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The CMG Voice

New Technology May Mean Major Advances In Diagnosing Brain Concussion Injuries.

Posted Monday, January 30, 2017 by Gene Moen

A Pennsylvania start-up company is developing techniques to allow doctors to see what is going on in the brain when it suffers an injury — without opening up the skull. When a serious brain injury occurs, brain cells are stunned with massive depolarization, which results in an “electrical storm” that is akin to a tidal wave tracking across the brain. The start-up company, CerebroScope, is developing a device that can detect these brain “storms” by using an noninvasive, EKG-like device that senses changes in the brain electrical system.

The hope is that, eventually, this technique can be used to diagnose concussions, which can affect up to 67,000 high school football players each year. At the present time, there is no medical device that is able to do that. Concussions cannot be diagnosed by blood tests, x-rays, or other scanning methods. The current methods of assessing cognitive changes, eye movements, and other signs are a crude way of trying to diagnose concussions.

The CerebroScope device would use dozens of electrical leads — like the ones used in EKG’s — to monitor the brain’s electrical activity. The leads would be attached to the scalp shortly after a suspected injury to determine if medical treatment is needed. The methods will be tested on humans in the near future at the University of New Mexico. Other institutions around the country are also focusing on research into diagnosing brain changes shortly after an injury occurs. The University of Cincinnati is working with others, including the University of Pittsburgh, in a similar effort funded by the Department of Defense. As one of the CerebroScope founders said, “concussion symptoms are all over the place; we know the brain short-circuits, but nobody knows how.” The hope is that the new devices and techniques will allow doctors to stop the tidal wave of cellular wreckage that comes with traumatic brain injuries.

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New Scientific Statement From American Heart Association Highlights Heart Attacks In Women

Posted Thursday, January 26, 2017 by Gene Moen

When we think of heart attacks, we picture a middle-aged man clutching his chest as he collapses to the floor. Yet the reality is that cardiovascular disease and myocardial infarctions are the leading cause of death in women in America. Despite that reality, there has been a decades-long effort to educate health care providers to the fact that disease risk, symptoms, and treatment are different for women than for men.

This has culminated in a new and lengthy “Scientific Statement” from the American Heart Association entitled “Acute Myocardial Infarction in Women,” originally published in January, 2016. It is intended to be a scientific “wake-up call” for those who diagnose and treat women with cardiovascular disease, and a detailed description of the gender-based variations in presentation, diagnosis, and treatment.

The statement emphasizes that “sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction.” The conclusion of the statement states that cardiovascular disease “is an equal-opportunity killer, and since 1984 the mortality burden has been higher in women than men.” These differences are often compounded in women of color. The differences in clinical presentation had caused delays in diagnosis and treatment of women with such disease. The conclusion also points out that compliance by women is often suboptimal, which highlights the need for ”continued public health messages and interventions to target racial and ethnic minority women.”

In the section of the Statement regarding clinical presentation, it is pointed out that, although most patients present with typical chest pain or discomfort, women often present with atypical chest pain and symptoms such as dyspnea, weakness, fatigue, and indigestion. As result, “the detrimental consequences for women are misdiagnosis, delayed revascularization, and higher [heart attack] mortality rates.”

A number of studies have also found that women present later to treatment than men (53.7 hours for women and 16.6 hours for men). This delay is often due to “lack of awareness of risk, passivity, inaccurate symptom attribution, and barriers to self care.” These problems are more pronounced in older women, lower-income women, and in African –Americans and Hispanic women. The statement ends with a call for better education of both the public and of health care providers in order to eventually end the myocardial mortality gap between women and men.

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A Recent Study Shows That “Doctor Apology” Statutes Do Not Reduce Malpractice Claims

Posted Monday, January 23, 2017 by Gene Moen

Many states, including Washington, have passed laws that allow a doctor to apologize to a patient about a mistake that was made, and the apology cannot be admitted into evidence if the doctor is later sued for malpractice. Washington’s law, at RCW 5.64.010, provides that if the apology (or offer to pay expenses caused by the injury) is made within thirty days of the act or omission of claimed professional negligence, it cannot be admitted into evidence.

The purpose of the laws is to encourage doctors to communicate directly and openly with patients when there is a bad outcome and express their feelings about what happened, rather than avoiding contact with the patient or family. Some studies in the past had indicated that this reduced the number of malpractice claims.

But a recent study, conducted by Vanderbilt University researchers, found that the laws are ineffective and, in some instances, may result in a greater probability that some doctors would be sued. The study used eight years of data from a major national malpractice insurer, and concluded that non-surgical physicians were more likely to be sued in states where the “apology” statutes are in effect, and that lawsuit rates for surgeons were unaffected by the laws.

The overall conclusion of the study was that “the evidence suggests that apology laws do not effectively limit medical malpractice liability risk.” While the laws may have encouraged better communication between doctors and patients, they have not had the intended effect of reducing malpractice lawsuits.

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Do Long Work Hours for Medical Residents Jeopardize Patients?

Posted Friday, January 20, 2017 by Gene Moen

A recent article in Public Citizen News takes the position that limiting work hours for medical residents is necessary to promote patient safety. This issue has been discussed and considered for years, with many hospitals and medical groups contending that such limits will reduce the depth and breadth of knowledge that residents need to become good doctors. Others contend that sleep-deprived residents make more bad decisions about medical care and jeopardize their patients’ health and safety.

Students who complete medical school and pass the qualifying examination become medical doctors, but in most states are not licensed to practice medicine. They can’t just “hang out a shingle” as a doctor and begin seeing patients. The requirement is that they must go beyond medical school to become “residents,” most often at a medical school or other facility. The residency is designed to give them from 2-4 years additional training, usually in a particular field of medicine in which they wish to practice. Examples would be radiology, cardiology, internal medicine, dermatology, etc.

The typical residency occurs at a medical school. There the residents often end up practicing medicine from day one of their residency. As they move through the residency program, their scope of responsibility expands and, by the time they are in their last year of residency, their scope of responsibility is often equivalent to that of the attending physicians at the particular institution. They are often also supervising residents who are at an earlier stage in their residency.

In years past, residents in hospitals often worked very long hours, at relatively low pay. It was not unusual for a resident to work 24-36 hour work shifts, with 8-12 hours in between. This was an obvious financial benefit to their hospital employer, since fewer residents could see more patients at less cost to the hospital paying their salaries. It also had some advantages to the attending physicians (usually on the medical school’s faculty) who had to spend less time actually seeing and caring for patients in the hospital.

Older doctors were often proud of the long hours they worked and some have resisted the trend to limit hours. They are like the Marine who boasts about the tough training program he had to undergo. But their argument is that long hours means the resident sees more patients in more different situations, and this contributes to the knowledge base needed to become a good doctor.

This issue is coming to a head with a task force of the Accreditation Council for Graduate Medical Education (ACGME) issuing a proposal that would allow first-year residents to work up to 28 consecutive hours. Opponents of the proposal point out that studies have shown that such long hours result in tired residents who are at greater risk of car accident, depression, and needle-stick and other injuries that can expose them to disease. And that just focuses on the residents themselves. Other studies show that medical residents, when sleep-deprived, put patients at risk because of poor thinking and error-prone medical decisions. Some groups are arguing for a cap of 16 hours per shift. But the opponents of such caps also argue that this means shorter shifts result in more transitions and “hand-offs” of patients between physicians, which can contribute to more medical errors.

There have been many studies showing the effect of sleep-deprivation on human behavior, such as driving or even just interacting with others. That is why there are strict limits on how long an airline pilot, train operator, or truck driver can work in one shift. Arianna Huffington, the author of “The Sleep Revolution,” has argued that “sleep-deprived doctors must make life-or-death decisions while dealing with long overnight shifts.” Whatever the final decision on work limits for residents, it will impact the residents, the attending physicians who supervise them, the medical facility that employs them and, most importantly, the patients who are under the care of the resident.

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Can You Appeal The Jury’s Verdict?

Posted Monday, January 16, 2017 by Gene Moen

Many non-attorneys ask whether it is possible to appeal a jury decision for the defendant. The answer is: “it depends.” All decisions by a jury about fact issues are final ones, as long as the trial was properly conducted and the appropriate law was given to the jury. The jury is the “fact-finder,” and its decisions cannot be appealed no matter how wrong you think they were. If the jury finds that the defendant was not negligent, or that its negligence did not cause the claimed injury, an appellate court cannot reverse the jury’s findings.

However, an appeal can be taken from actions of the trial judge may have unfairly shaped the jury’s decision. In that instance, the appeal is from the legal decisions made by the court, not from the fact decisions made by the jury. An example of a potential appeal would be erroneous rulings by the trial judge about what evidence was admissible. If the appellate court finds that the judge wrongly let in, or kept out, evidence presented by either side, it can then decide whether this error was substantial enough to have led to a jury’s decision about the facts regarding liability, causation, or damages.

Often, during a trial, either side will want a clear record of the judge’s decisions and the basis of them so that an appellate court can weigh whether a substantial mistake was made. Some attorneys will not make objections to evidence submitted by the other side, or not submit evidence that the other side objects to, because they worry that it might create an appealable issue. This is an area where the trial attorney has to weigh the risks and benefits of the position she or he takes on these matters.

Another key example of an appealable decision relates to the judge giving the wrong law though the jury instructions at the end of a case. Jury instructions are exactly that: instructions to the jury about what law applies to their deliberations and ultimate fact decisions. In Washington, as in most states, there are a set of published “pattern instructions” that are the product of a committee comprised of representatives of both plaintiffs and defendants, as well as judges. The committee meets regularly and will devise new pattern instructions on occasion to deal with changes in either legislation or in case law enunciated by the Washington Supreme Court.

Most pattern instructions, if given by the judge, will not result in reversible error. But in some cases the instructions don’t truly cover all of the legal issues in a given case, and either side can submit proposed instructions that are variations from the pattern instructions. Exactly how they are worded may be a basis for an appeal by the side that contends the instruction misstates the applicable law. Some attorneys are reluctant to propose anything that varies from the pattern instructions because of worries it might be the basis for an appeal by the other side if you win your case.

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