FWD: FactCheckEd

FactCheck has a new offshoot: FactCheckEd, with exercises and lesson plans
intended to teach critical thinking and media analysis to students. So far,
they have two things of interest to our list: Listerine and Hoodia products.
See http://factchecked.org/LessonPlanDetails.aspx?myId=1

Medical Ethics vein clinic example

An appointment for a consultation with an MD was made recently (referred by
GP for some moderate edema in the lower legs) and, before meeting with the
doctor and without warning or explanation, the patient suddenly found
himself on a table with a sonographer--whom he first assumed was an
RN--scanning his legs.

Neither the GP's RN (who originally scheduled the consult) nor the patient
(when he rescheduled) remembers any caveat regarding the need for an
expensive sonogram.

The bill total was over $800 US for the sonogram and the consult and before
the patient could leave, the office assistants were trying to set up an
appointment for both saphenous veins to receive a "Closure" procedure using
an RF emitting catheter (see www.vnus.com). As might be expected, the
calendar was rather full and only one date was available for the next
several weeks. Additionally, the procedure's success rate was stated as 99%
(this may be correct but one might not be surprised to learn this number is
on the high side).

Despite a request to not submit to insurance for pre-authorization until
advised, the office (which had offered to do immediately) did it anyway.

The patient is not going to have this or any other procedure done without at
least one additional opinion and is interested to know if he should be
advised to avoid this particular MD regardless of his extensive experience
and credentials.

The doctor's office was not paid (the bill wasn't ready and they we told not
to bill insurance); the patient intends to tell insurance to hold claims
until this is resolved. Of course, it is assumed the sonogram results
belong to the patient and that they could be requested by another
practitioner so it isn't likely there will be lack of payment unless a
sonogram clearly was not indicated based on the state of the medical
condition. In any event, the patient got a sense he was being given the
bum's rush; maybe what one might experience on a visit a high-powered
chiropractic office.

Any opinions on the ethics involved here would be appreciated.


Regards,

P H

______________________________________________________________



This sonogram-without-consultation case sounds like poor communication by clinicians and/or poor understanding by the patient. To infer an analogy, last time I went to the dentist, the office crew fiddled-around in my mouth and took x-rays before I even saw the dentist.

I bet this patient was referred to one of them new commercialized "vein clinics" we've seen popping up all over with the full page newspaper ads and tv/radio commercials. It would be pretty common, I suspect, for a vein clinic to sonograph a GP-referred patients legs at the first visit. And, unfortunately, we've come to a day when many specialty clinics give the impression they want to see your insurance card and talk to your insurance before they want to see or talk to you.

So, this case scenario might be more of a quality care versus blatant breech of ethics issue. However, I think much of what I've seen with vein clinics goes beyond poor patient interaction and becomes a good example of poor medical ethics. Coil embolization of the saphenous vein via VNUS RF catheter technique seems to be a primary staple for income for these specialty vein clinics. It almost gets to the point where anyone who steps foot into the vein clinic is going to have an indication for this, and/or equally intensive vein procedures. Patients eventually get rubber-stamp treatment despite any disparity in clinical history or presentation. This is a gray and dangerous area in regards to medical ethics. But, I bet the risk for this isn't anywhere unique to vein clinics in the larger medical community.

N-

Naturopathy--How to fix a leaky roof

http://www.newstarget.com/021787.html

From the article:
"...The difference between conventional medicine and naturopathic medicine can be described in the way that health practitioners would perceive this problem and attempt to resolve it. Conventional medicine would look at the water dripping out of the roof and find a way to measure it. So they would have a number, which might be 60 drips per hour, and they might say anything above that (such as 70 drips per hour or 100 drips per hour) is a disease, and they would name that disease something like, "Roofoporosis Disease."
"They would identify the symptom itself -- the water -- as being the disease, and they would try to figure out which chemical would take care of it. In this case they might prescribe water absorbing crystals that you would spread around the house to absorb this excess water, completely ignoring the integrity of the roof, as well as the need to actually repair the roof and not allow water to drip through it. If you said to them, "well, maybe we should think about repairing the roof," they would say, "The problem is clearly the water -- you can see the water, here's a measurement of the water." They might even say if you don't aggressively treat this excessive water, you're going to end up flooding your entire house.
"In contrast to that, a naturopathic approach involves a little more investigative work. A naturopath would use the dripping water as a clue, but then ask: what is the underlying fundamental cause of this water dripping into the home? The naturopathic physician would trace the water back to the stain in the ceiling, and this stain would indicate that water has been chronically dripping in from a leaky roof. Then, he would trace it through the attic to the roof and find a hole in the roof. After a bit of detective work, he (or she) would decide to patch the hole, repair the roof and stop the leaking water at its source."


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I think the "leaky roof" analogy is excellent. Just a little wrong.

In conventional medicine, there is an understanding that all roofs leak, in fact it is healthy that they leak to a degree. Based on study, conventional medicine concludes that too many drips per hour is unhealthy. Then, it's decided how to best remedy "Roofoporosis." A bucket under the drip is the cheapest effective method, and many are completely satisfied. After all, why prod and poke the roof looking for leaks, or start replacing it, if a simple bucket is all that's needed at the time? Depending on additional leaking or other circumstance, the conventional doctor might recommend other alternatives to treat "Roofoporosis"

In naturopathic medicine, dripping water is a clue that something about the house is wrong. They send the water for mail-order food allergy testing and immediately check all the doors and windows. After all, if the roof is leaking chances are the doors and windows are compromised as well. (A puddle just inside the Doggy-door is a particularly ominous finding.) Once several house leaks are suspected, or identified with electromagnetic testing, a holistic approach to maintain household hydro-integrity is implemented. Herbal sealants are used structure-wide and room-to-room recommendations about color enhancement and furniture placement are made. Depending on patient willingness, a full analysis of the house plumbing is planned.

N--



Dale

pranayama and the Buteyko Breathing Technique

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Question for [N-]: why don't RRTs and others empirically try alternate
nostril breathing on patients in respiratory distress? What about
ethics? Regards, Richard Friedel


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Back in the early 90's when I did practice as RRT in the ER, breathing techniques with nasal breathing was a part of what was done for the patient admitted with acute respiratory distress. In conjunction with medical evaluation, treatment, and medication, we did whatever to comfort the patient, and tone-down and calm the environment. From speech and mannerism, to curtains, lights, and sounds. Depending on the circumstance, the patient was coached different ways to make the exhalation phase longer, or use diaphragm instead of shoulders and intercostals to breath. I never felt like I was sneaking in Yoga meditation rites, or preaching a vague "CO2 theory" supporting treatment.

I know there's a new fad with measuring exhaled NO in asthma, but I had not heard of "Decreased pulmonary vascular resistance during nasal breathing: modulation by endogenous nitric oxide from the paranasal sinuses", but I don't doubt it. This study contributes to the growing research we have on NO, but I'm still waiting for the practical utility that NO treatment studies seem to promise.

On the topic of nasal airway resistance in asthma, I stumbled on the following that, based on the abstract, doesn't find anything we wouldn't already expect:

Duggan CJ, Watson RA, Pride NB. Postural changes in nasal and pulmonary resistance in subjects with asthma. J Asthma. 2004 Oct;41(7):701-7.
"...DISCUSSION: Values of airflow resistance are 2-3 times higher in both normal and asthmatic subjects when breathing via the nose and supine than under normal laboratory conditions of oral breathing and seated."

I went out to the Internet for a quick review on the status of breathing retraining for asthma, including pranayama and the Buteyko Breathing Technique in clinical medicine:

http://en.wikipedia.org/wiki/Buteyko_method

Holloway E, Ram FSF. Breathing exercises for asthma (Cochrane Review). In: The Cochrane Library,Issue 1, 2001. Oxford: Update Software.
"...The researchers concluded that breathing re-training might be helpful as part of the treatment of asthma, but that the data available are insufficient to prove it, due to the small number of studies, the small number of patients studied, the different types of interventions employed, and the inability to obtain further data from the authors."

http://www.mja.com.au/public/issues/xmas98/bowler/bowler.html
e-Medical Journal of Australia review

http://www.jr2.ox.ac.uk/bandolier/booth/alternat/breathexasthma.html
Bandolier 2000 review

Gyorik SA, Brutsche MH. Complementary and alternative medicine for bronchial asthma: is there new evidence? Curr Opin Pulm Med. 2004 Jan;10(1):37-43. Review.
"...Strategies influencing breathing technique or perception, such as breathing or retraining exercises, need to be studied over the next few years to establish their additive role in the treatment of asthma..."

Bruton A, Lewith GT. The Buteyko breathing technique for asthma: a review. Complement Ther Med. 2005 Mar;13(1):41-6. Epub 2005 Apr 18.
"...The BBT 'package' is complex, as it also includes advice and education about medication use, nutrition and exercise, and general relaxation. This makes it difficult, and possibly inappropriate, to attempt to tease out a single mechanism."



Yours,N-, RRT

FWD: Religion and Vaccination

Re religion and vaccination:

Recently, the United Methodist Church has been persuaded to support the "vaccine safety" campaign of Rev. Lisa Sykes, assistant pastor to a Richmond VA Methodist congregation and plaintiff in the $20,000,000 thimerosal product liability lawsuit, Sykes v. Glaxo. In 2005, the VA and KS Conferences of the UMC passed thimerosal-ban resolutions, and the Women's Division is sponsoring a "vaccine safety educational event" at Simpsonwood Retreat Center on June 6-7, in collaboration with the thimerosal plaintiffs' advocacy group, Moms Against Mercury. They're planning yet another demonstration at the CDC. This is all part of the big push by plaintiffs to attract media attention to the upcoming Omnibus Autism Proceeding causation hearings.

Two days ago, I sent a letter in protest to the Council of Bishops, the General Board of Global Ministries, the General Board of Church and Society, and the Women's Division of the United Methodist Church, and the Virginia Interfaith Center for Public Policy, entitled "A Plaintiff in the Pulpit: Problems With United Methodist Church Advocacy on Behalf of Vaccine-Injury Litigants." I've blogged it at:
http://neurodiversity.com/weblog/article/126/

It's long because it's well-documented. Please feel free to pass the link on to anyone who might feel moved to speak their mind publicly about this -- especially Methodists. If anyone needs email addresses of the people to whom I sent the letter, feel free to write me off-list.

Kathleen Seidel
eurodiversity.com | honoring the variety of human wiring
http://www.neurodiversity.com

AAP addresses myths about vaccinations

Earlier this week, I was fortunate enough to have the spokesperson for
the American Academy of Pediatrics speak to my public health students
about vaccination facts and myths. She was also kind enough to allow me
to put her PowerPoint slides on my website. Although they don't fully
convey the great talk she gave, I think that have some great information
and perspectives on the issue of childhood vaccinations.

For anyone who is interested, they can be found at:
http://www.csun.edu/~hchsc018/345/vaccinations.htm

More nose functions

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TLC, or total lung capacity is measured two ways, helium dilution technique, or using pressure measurements taken during body plethysmography. Neither testing method is significantly impacted by airflow. In the PFT lab, VC is measured through the mouth with nose clipped, with a forced breath out then back in. The volume measured is not necessarily flow dependent because the subject continues to exhale until no more flow is detected on spirometry. The residual capacity, RC, or amount of air left in the lungs after complete exhalation is calculated using the TLC minus the VC.

I think you are correct in that your overall respiratory function is nose dependent. And that is something not generally considered in the pulmonary function lab. Consider that the nose makes sure inspired air reaches the lungs at body temperature and at 100% humidity, and provides a back pressure to the lungs on exhalation that is beneficial to gas exchange. The senses including temperature and smell in the nose can cause involuntary physiologic responses. So, maybe there is an avenue for clinical study to learn more about how the nose plays into respiratory-related disease. Maximum ventilatory volume (MVV) is a test used to understand the extent of air obstruction or restriction, and is done with the nose clipped and the patient hyperventilating for one-minute. But, as mentioned in my prior post, both established tests for measuring nasal obstruction and nasal restriction in the nasal passages has not panned out to clinical utility.

What about nose breathing?

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Nose breathing involves a little more resistence to airway flow versus mouth breathing. The resistance also provides some back pressure into the lungs - some PEEP, for those familiar with the discipline. This might explain being able to expel a little more air through the mouth following complete exhalation through the nose. The concepts of PEEP, and natural PEEP are well- studied and used. From "Artificial noses" in ventilator circuits to pursed-lip breathing when you get a runner's cramp. I also doubt the little better alveolar air exchange (they will not collapse) you get from a complete mouth exhalation makes any noticeable physiologic difference.

Several years ago there was a lot of todo over Rhinomanometry testing of nasal airway resistance, used for example, as an assessment in allergy clinics or as a protocol in the work-up for sinus surgery. But, no one has really demonstrated that testing results in anything uniquely clinically meaningful. There are gadgets for Rhinomanometry testing (and even an AMA CPT code), and also some for Acoustic Rhinometry for measuring nasal obstruction around so I'm sure there are practitioners of one sort or another advocating their use for one reason or another.

n-

Resparate Machine, Again

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The Bird Mark 7 ventilator was invented and marketed by Forrest Bird in 1958. In a degree due to Dr. Bird's business prowess, the biggest market for this machine by the mid 1970's was not for anesthesia or for treating respiratory failure, but for treating patients with respiratory risk or compromise. IPPB (intermittent positive pressure breathing) therapy was advocated for post-operative, and about any bed-confined or pulmonary compromised patient. Crowds of these "Bird machines" lined hospital hallways, and the profession of Respiratory Therapy virtually established its existence in the technical delivery of IPPB therapy. However, the likes of the Bird machine became virtually extinct in hospitals by the late 1980's. A better scientific understanding of pulmonary physiology, studies in nosocomial infection, and the demise of fee-for-service hospital billing all played a part. Nevertheless, today, instead of complicated, expensive, time consuming, and risky IPPB
therapy, the same respiratory therapist coaches the patient in simple breathing and coughing exercises, sometimes with the assistance of a 8 dollar disposable toy, to a superior health benefit and outcome than IPPB.

What does this have to do with the RESPeRATE? Some correlation should be obvious. In 1970, we wanted to do something about people getting pneumonia following surgery, or while bed-confined in the hospital. Dr. Bird prooved the Bird Mark 7 and IPPB could do just that. And besides, it looked high-tech and provided revenue for the hospital. But, it turned out NOT to be the better, simpler solution to the problem. Today, we want to lower our blood pressure, and the RESPaRATE might prove to do just that. But, I am convinced that, like IPPB therapy, it is not the simpler, cheaper answer. With IPPB, we found that simple, frequent breathing and coughing exercises provided excellent outcomes in reducing pulmonary complications. With RESPeRATE, I'm sure we will find that simple relaxation (meditation) and breathing exercises will provide similar, if not superior benefit in lowering our blood pressure. That is the study that should be done before we consider any high-tech,
rich reimbursement enticement. Either that, or look at the RESPeRATE for what it should be: a simple, but helpful, 8 dollar toy.

N-, RRT