PSOTBLOG

Lilly Settles for $1.42 Billion

 
Eli Lilly agreed to pay $1.42 Billion to settle aprobe into alleged improper marketing of the antipsychotic drug Zyprexa[olanzapine]. Zyprexa shichis approved to treat schizophrenia and bipolar patients, has been Lilly's top-selling drug earning more than $37 billion in sales since 1996. They systematically instructed their representatives to play down side affects and encourage the drug for unapproved indications ranging from migraine to dementia.

 "The settlement removes the specter of a criminal indictment of Lilly, shich couldhave threatened the company's lucrative business with Medicare and Medicaid."
 
A group of us had argued that these companies were infiltrating the integrity of our state medical meetings at the TennAAFP(the AMA state meetings stopped any pretense of CME over 15 years ago). Our attempt to remove drug sponsorship of our Memphis meetings resulted in the state chapter disbanding our meetings with bogus claims of financial illegality when we  basically bought our own suppers and invited the spouses to attend.
 
I remember Ric Richards and Paul Fischer of the Georgia chapter warning us twenty years ago. They were not extolled as heroes.They have since left family medicne academia and the leadership roles they once held. Here it is again. Wall Street Journal Jan 16, 2009 pB4. and USA Today pB1
 
Could the state AAFP meetings exist for the purpose of being a better doctor and without drug sponsorship? Memphis and Nashville have not held local meetings of family physician members for over two years.
 
Here's a parting headline to remember the way we were. "Researchers say Vioxx study was a marketing ploy. Goal was to create demand for drug" Tennessean. Aug 20, 2008. p2E.
 
I hope that in 2009, local physicians can revive themselves and form a core of leadership dedicated to the higher goals of what family medicine can do as the antidote to this corruption which has infiltrated the highest levels of some medical schools and some medical societies.
 
With best wishes for a Joyous New Year,
 
Wm MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural
www.psot.com

Index--med4uninsured, Medicos mission

Medicos J Club-Abcesses and Sepsis

 

 

How many times has Medicos seen relatively young people with abcess requiring incision and drainage? Many. Most have heard my advice to not use antibiotics routinely for these abcesses, but there are some dramatic exceptions. Who can forget the workers we see with fever and white counts greater than 20,000? The New Engl J Med Jan 15, 2009 has an interesting review of a young  man similar to the ones seen at Medicos. The presentation photo looks like this.

The review gives a defintion for severe sepsis and it is worth repeating. T greater than 38 C(100.4 F), P greater than 90 bpm, RR greater than 20 per minute, and a white cell count of greater than 12,000. This young man went on to develop septic shock whiich is defined by the above plus a persitent hypotension  with BP less than 90/60 despite adequate volume resuscitation. This case developed septic shock due to necrotizing fascitis of the hand and forearm. You won't see many of these fasciotomies in a lifetime, so let's look at this one. The recovery photo after skin grafts is to the right.

Four months later he went back to work as a welder. How can we use this case at Medicos?
Every year Medicos manages over 300 routine abcesses as part of its office surgery curriculum for residents and fellows. Of these, 2-5 are abcesses with sepis. These septic cases are managed using daily visits for antibiotics in the office. This is one reason we recommend a hemogram (CBC) on abcess patients with fever, severe pain, or tachcycardia. A high white count drives us to add antibiotics parenterally. In our mission hospital example Medicos is using IM antibiotics with reasonable coverage for staph and strep. This one was strep.
 
Senior physicians do not recall having received wound culture results in time to change mangement and, similar to the discarded recommendations for routine blood cultures with pneumonia, we have managed fine without the cultures. In twenty years of experience, we did not recall wound cultures helping us with management. I'm sure exceptions exist. No need to send the anecdotes.
 
In 1999, Medicos stopped wound cultures with rare exceptions. We have not had one failure for lack of a culture. If they need a culture patients probably should be in the hospital. Since most young physicians are frequently  trained to always get a culture, this creates a self-fulfilling prophecy regarding the constant need for higher and more expensive levels of care. Medicos reflects on its experience as being different and equally effective.
 
The man above needed to be in the hospital and in the Or because he progressed from a simple abcess to necrotizing fascitis to sepsis to septic shock and a compartment syndrome requiring aggressive surgery.
 
With best wishes for your professional success,

WMR
 
In the case of skin and deeper tissue infections we have to differentiate as early as possible the Abscesses from the "cellulitis". Abscesses (boils, Carbuncles) are in general easy to treat and needs I&D. MRSA acount now for the mayority of them. If you are giving something: Bactrim, Doxi or Clinda. Fever tend to be hectic, and general status is good, surrounded tissues are not painful or infected."Cellulitis" are "non restricted to a wall" infections, then tend to disseminate to surrounded tissues. Agree with the idea of "no cultures" but in out environment the residents (and we) are worry of "why you did no do cultures"-people. Blood cultures, and local cultures are not useful, just the same that many others we do in the hospital, and as an outpatients (my best example is the routine postpartum H/H). The "cellulitis" needs agresive Tx with Antibiotics and close f/u.

my 2 cents.

Eduardo Scholcoff
Rockford, IL

Don't know if my experience represents the "usual" presentation but I have seen 2 cases of rather aggressive strep cellulitis that almost resulted in finger amputation despite early and fairly aggressive antibiotic treatment.  The first time I saw it was in Conway Arkansas (Razorback strain) in which a healthy young man came in with a very UN-impressive 0.3 cm abscess on his finger.  I remember that the tissue did not look normal during the I&D.  The really unusual symptom was sudden onset of very high fever and body aches (like strep throat-duh).  He had extended stay in hospital and almost lost the finger. Second case was in Hot Springs Arkansas (Razorback strain beta).  Healthy man came in on the way to his mothers funeral with exact same presentation. I told him that he would think I was crazy but that he would probably feel very bad soon - he was back in 30 minutes and admitted to the hospital. Anyway, when I see abscess, fever and body aches that are out of proportion to the wound I perk up a little! In Tennessee, have only see MRSA (Volunteer strain Memphis Type Alpha) which has seemed to eradicate any strep that may be present.  Had one particularly bad finger (again) infection and ID doc told me to give Bactrim DS TID and Rifampin.

No great mystery solved but thought I would contribute to the Journal Club instead of constantly sucking information from it. Thanks to all you veterans that have made this ONE OF THE FEW actual learning experiences available.  It sure does not look good in the neighborhood but wanted you to know that your efforts are greatly appreciated.
 
Perry Rothrock
memphis 
Terrorist Unit #1, 
Charter Member

Perry:

That was my point: boils can be there for several days, they are unconfortable, BUT THEY DO NOT SPREAD !!!!!!!!! very uncommon body aches, besides the ones you have when temp spike. "I remember that the tissue did not look normal during the i&d" !!!!!!!!!!!!!! your statement !!! Then I'll see him again. F/U his temps etc.
Eduardo. Rockford IL

 

Vaccines for Children Program

Medicos had meetings with the Vaccines for Children Program of Tennessee

—Questions submitted by Daniela Garcia MD and Proposal for Discussion

January 19, 2009—wmr

1.Is Medicos going to offer the HPV[Gardasil] vaccine for patients?

Yes, through the VFC program, but Medicos will not buy it for private(non-VFC eligible patients.) Non eligible patients requesting  Gardasil should be referred out of practice for these service. The health department, and Dr.Rothrock on Germantown Parkway in Memphis offer private vaccine services.

Controversy remains regarding the long term benefits of this HPV vaccine, and it does not replace the need for Paps surveillance among sexually active women. Medicos’ vaccine priority is established and tangible healthcare benefit, AND the ability of our children to enter American schools. Failure to have specific vaccines prevents admission to the public school system. Gardasil is not one of them.

Students are not required to have Gardasil, rotavirus, or Hep A for the Tennessee schools. Therefore Medicos’ priorities remain the other vaccines. Parents have right to refuse vaccines, but must sign a waiver. Please comment and update.

2.Is Medicos going to offer rotavirus vaccine to patients?

Yes, but each physician has a right to prioritize the urgency of vaccines.  Getting into school is a priority. The administration guidelines are not “law”. Clinical judgment and availability of various vaccines will cause the schedules to be imperfect. For example, receiving Hep A at exactly two years of age is not an emergency.  Is the vaccine available today? Can the family come in on exactly the correct date? How sick is the child today? Is it clinically reasonable to wait another 3 months when clinical conditions and availability are more favorable?—All of these questions create the need for flexibility and clinical judgment. Perfectly timed administration is the exception, not the rule.

3.What is the charge for the vaccine shot[ie administration]?

The federal allowable is $13.75. Medicos seeks to have reasonable fees and no child should be denied VFC for lack of payment.  Medicos will be upgrading its fee schedule in such a way that Medicos would never charge more than the allowed amount. Effective immediately Medicos’ fee schedule will be changed to $13.50 per injection which is slightly less than the federal allowable. The code for one injection is 90471. The Code for two or more injections is 90742 times the number of injections given.

Rota virus vaccine is not an injection, but I think physicians can bill an administration charge. Billing, help me out here.

4.Does the injection fee mean that we do not charge for the vaccine?

Medicos does not charge for VFC vaccines, but, on the super bill-encounter form, physicians must document the vaccines given. Billing does not charge for these vaccines even though the physician has circled them.

5. Can patients with private insurance receive vaccines? 

If private patients cannot receive stock from the VFC program, where do we refer them? Medicos can and will give Td vaccines to workers with injuries and other adults as needed. This is the only “private vaccine Medicos will stock. It will be kept in a separate refrigerator apart from VFC stock.

Blue Cross Blue Shield private, Aetna private, Humana private—should be referred to the health department. The Medicos upstairs may become a different office where all private vaccines are kept. Stay tuned for new developments.

6.Is Prevnar going to given again at 12-15 months? In other words, do we give 4 doses?

Medicos is awaiting the decision of the Memphis and Nashville city schools about these extras shots as a “requirement” My interpretation is that there is confusion about what is “required” versus what is “suggested” I do not know the exact answer to this question right now.

7.Is the HIB booster dose going to be given to every patient at 12-15 months?

Same answer as above, but Medicos has time to work this out as Medicos comes to its first audit in April- May. A lot of this depends on the supply of HIB whose shortage currently makes this almost impossible to do. The new combo HIB, DTaP, ? vaccine may help here. Your comments and suggestions are appreciated.--wmr

Index--Vaccines for Children

Fellowship Curriculum Design

 
REPLY FROM MEDICOS FELLOW MICHELE WALSH MD 2007-2008 NOW PRACTICING WITH CHRIST COMMUNITY CLINIC IN MEMPHIS
 
I agree that it is hard as a prospective fellow to know exactly what training will best prepare you because you don't know what you may need to know when you are out. It is easy to get fooled by numbers and "hard cases".
 
In my experience, the training that really needs to happen is how to manage patients in an outpatient setting through their preganncy and then how to safely deliver them. It is relatively easy to deliver a diabetics baby and manage her in the hospital where consultants are available and the patient is always ready for more tests. It is not so easy to manage her prenatal care. It is realativel easy to do a section on a pre-eclamptic patient or one with HELLP syndrome -- the hard part is diagnosing it and appropriately managing it until she gets to the hosptial.
 
It is also important to be able to do good ultrasounds in the office. Otherwise you send lots of people to the hosptial for u/s and delay management or lose managing their case altogether. THe hospital I am in now doesn't have u/s techs at night and won't call them in so we perform them on the floor if we have a patient in triage who has a problem -- and I am glad I am confident in my u/s skills.
 
So, my personal opinion is that having good prenatal experience and ultrasound experience is critical in training. It is also helpful to have a average volume of c-sections. I did about 140 and once I hit the 100 mark had seen twins, breach, transverse, placenta previa, uterine extension, bladder injury, etc. practicing repairs in a pig lab model was also helpful.
 
Seeing/performing some hysterectomies is also helpful and if you find an OB/GYN who is willing, they will usually let you assist (if there are no OB residents). It is impossible to be prepared for everything. Some cases require lots of prayer and God's grace. However, being well rounded in training, seeking experience where possible and knowing your back-up support will serve you and your patients well.
 
My 2 cents, Michele Walsh MD

Index--OB Fellowship curriculum, how many complicated deliveries are needed?, respsonse from recent fellow

Fellowship Experience in Complicated Deliveries

A fellowship candidate asks a good question

--Dr Rodney,

I was wondering if you can tell me a bit more about a fellow's typical experience in non-NSVD such as breech deliveries, twins, and other complicated deliveries such as pre-eclampsia, pre-term, GDM. I'd like to know how many complicated deliveries a fellow would manage and how involved they are in the management. Thanks.

REPLY-(WMR):

Physicians face a real dilemma regarding their anxieties about being undertrained for the emergencies they may eventually encounter. No one can ethically create a high volume of emergencies for the noble purpose of "improved training". Fortunately the general principles of the Medicos curriculum seem to have carried our fellows through the past 18 years. In 2008, our three fellows participated in somewhere between 300 and 400 sections. Res ipsa loquitur.
 
But, one area of needed research is the relative paucity of "bad cases". ALSO was a step in the right direction, and training simulators exist. Who is there to hire and reward the needed legions of high touch FP educators teaching these procedures jealously guarded in most academic medical centers?
 
Medicos fellows may do 2 fourth degree repairs in a year. Our fellow did one this week without help. He has not previously done many. If the fellows would use more forceps, they would get to do more fourth degree repairs. Should we be teaching forceps as a requirement or an elective? In Memphis, the obstetricians have stopped teaching their residents as a requirement. Each year I offer it, but the fellows never pursue it. WE have a forceps teaching module ready if anyone wants it. Medicos conducts a surgery lab for fourth degree technique.
 
In four years, none of the OB-Gyn residents attain the ultrasound sophistication reached by our fellows in one year. Unfortunately, or fortunately depending on your perspective, the ultrasound and risk management process of Medicos eliminates a number of emergencies and perinatal deaths. Medicos has been carrying an omphalocoele picked up at 19 weeks with the heart free floating in the omphalocoele which is free floating in the amniotic fluid. I saw her today at 26 weeks.
 
The family has been precounseled about inevitable death should labor come before 28 weeks and probable death if she does not stay close to the major neonatal center availble here in Memphis.  We are in prayer with the family. When this delivery occurs we will be prepared. If the baby lives to 36 weeks , she will not have a vaginal birth and we will not do the section. But, did we learn something valuable? I think so. photos later.
 
How many preterm deliveries should be managed before a physician can be deemed "competent"?  American physicians have become "numerologists" when it comes to credentialing, but the answer is more metaphysical than scientific. Preterm management can be learned by telephone, but success will usually depend on the availablilty of an NICU.
 
Every month our fellows seem to conduct at least one pre-eclampsia drill. The use of magnesium sulfate seems to be the sine qua non of this experience, but probably mag sulfate should be replaced with nifedipine. In ten years we have had two HELLP syndromes. We sectioned them both successfully. If pre-term is defined as less than 37 weeks,Medicos has one a week. If pretem is defined as less than 34 weeks , Medicos has 8-12 a year. Every month Medicos carrying at least 15 GDM cases at various stages of gestation. Medicos will not carry any insulin requiring pregnancies.
 

Index--OB Fellowship MedicosMemphis, complicated deliveries

Automatic Entry of ECG into EmR Proposal

Medicos has a template for ECG interpretation and it may be best to start filling it in. when complete it should be printed and filed for QA.
 
IN REPLY TO DR CHIU'S ANALYSIS:

ECG image transfer is possible. However, it requires practice partner team to do interfacing with the QRSCard team. If it is a priority, we can put in a call. It is not straightforward and will require modification / patching of practice partner code on the server by PMSI / McKesson.  The other option is to use PP_ZOOM which will suck up space like you would not believe on our server with limited disk space.
 
I think the best option yet is to have a quicktext for cardiac EKGs that mirror what you have on the EKG interpretation form.
 
Let me know what you'd like to do.
 
James

Since the explosion of patient volume at MedicosMemphis this month, I have been looking for the most immediate efficiences to help the doctors reduce keystrokes and paper shuffling.
 
Automatic entry of vitial signs by medical assistants at the front. Has this been  possible at Nashville?
 
automatic trasfer of ECG imiage into the aptiens record withinterpretation format already in the computer.\
 
Comments appreciated.
 
With best wishes for a Joyous New Year,

Dr Rodney

Index--ECG interpretation files, EMT auto entry

Latest Numbers

Memphis 371 deliveries and 200+ training Cesareans for the felllows from other physicians.Nashville 240+ deliveries; still working on Cesarean rotations for the fellows; Hope to establish collaboration with Tuscaloosa or Huntsville OB.
 
Special thanks to Carlos Osorio and Vanessa
 
With best wishes for a Joyous New Year,
 

 " Medicos-where 10 percent of the information makes over 90 percent of the difference and where,through Grace, twice the service is provided at less than half of the cost." Constructed and maintained without government grants or charity. A design laboratory for the development of mission hospitals and independent physicians who provide continuing comprehensive health care unrestricted by age, gender, organ system, and location of service. A rural simulation in a city.

 
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Clinical Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural

Frenotomy Part Three

I just sent a sampling of articles I'm familiar with, I was actually pleasantly surprised to discover that there were several more when I did
the medline search to get the citations to send you.

My criteria for clipping are pretty simple: anatomic finding of ankyloglossia plus functional problem of either maternal sore nipples interfering with breastfeeding or poor milk transfer (almost always have both). I sometimes use the topical anesthesia but not always if the frenulum is very thin--almost makes the babies more mad to use it I think. I snip the insertion at the tip, blunt dissect with my finger, hold pressure for a couple of seconds if there's any bleeding, then let the baby nurse immediately (that pressure stops any additional bleeding and the nursing makes the baby and the mom happy). Often one of the few instant cures in medicine.

Unfortunately, however, if it is done late in the course of problems, one still may have dysfunctional suck patterns and a poor milk supply to deal with so I always tell moms that it may not instantly solve all of the problems. In addition to being a Fellow of the Academy of Breastfeeding Medicine (the only currenlty available physician credential; we're working on a certifying exam/CAQ type of "board"), I'm also a lactation consultant so fortunately have the expertise to assess and address more than just the tongue tie. For those of you who don't have these skills I would suggest being sure you have someone you can refer to for additional help if you are going to clip tongues.

I understand some "granny midwives" back in the old days used to keep a long pinky fingernail and take care of these right at the time of birth!

Anne M. Montgomery, MD, FAAFP, FABM
Faculty Physician
Family Medicine Spokane

Thanks for the update, Anne. I learned to do the frenotomy from a pediatrician that I worked for while I was in medical school. I have continued to do the procedure in the office and never had any troubles. Like everyone else, I don't do a lot of them. As a former speech pathology major, I was relying on my info. from undergrad that there are situations where they can be helpful. I usually do it in the situation where there seem to be some breastfeeding difficulties and an obvious "tongue tie." Thanks, Anne, for reaffirming what I thought I knew.

Aline Coonrod, MD
Faculty Physician
North Colorado Family Medicine
Greeley, CO
 

ur ENT's do them in the hospital. Thus doubling (or tripling) the cost of the procedure to the patient or us. Papoose board, nurse assistant, battery powered cautery, all available in the office.

Roger KimberO
 

3rd year Resident Memorial Hospital South Bend, IN
I have only performed one, and it was in the nursery.  Baby was feeding poorly, mom was complaining of pain with breastfeeding and was about to make the similac-swap.  The child had a heart-shaped tip of the tongue due to frenulum.  Iris scissors, about 2-3mm, child fed within 5 minutes with mother being much more comfortable on the nipple, continues to feed as outpatient.  Anectdotal, but true.

Andy Shull