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Narcotic Overdose and Other Problems
Posted by: William Cirignani
March 27, 2008
Topic: Medical Error: Medications and Overdose

We are frequently asked to review cases where a family suspects that their loved one may have died from a negligent overdose of painkillers (opioid narcotics, oxycodone, etc). In analyzing whether there was negligence we have to look at two things: the patient's response to drugs, and the doctor’s response to the patient. Let me explain.

Patient Response To Drugs

While there are general guidelines that describe a maximum safe dosage of painkillers, the reality is that safe dosages are patient-specific.Not only are there difference among the various painkillers, patients have different reactions to the different narcotic medications. These reactions can change from drug to drug, as well as from use to use. One reason this occurs is called opiate tolerance. When a patient use one specific type of painkiller over a long period of time, they can build up a tolerance to the drug’s effects, meaning that they might need more of the drug to gain the same level of relief. Conversely, if a patient has never used a particular painkiller, they are sometimes called opiate naïve.

In either case, a doctor must obtain a full history from the patient about their painkiller use before deciding which drug to use and in what dosage. Often, when a patient is in a pain crisis they may not be good historians—they may not be able to recall the medications they’ve used in the past. In such cases, the doctor must review the patient’s chart, or, if it is a new doctor (say, during an emergency room visit), the doctor must contact the patient’s prescribing doctor to get that history. For this reason, if you are a chronic pain sufferer, it is often a good idea to carry your doctor’s contact information in your wallet.

In addition to the patient’s history of painkiller use, the doctor must also consider: the other drugs used in mixed preparations (“painkiller cocktails”), and cross-tolerance. Caution is the guiding principle whenever new painkillers are started, or when increasing dosage of existing painkiller regimens.

Doctor Response To Patients

As noted above, patient reactions to painkillers can change from drug to drug, as well as from use to use. Therefore, it is imperative for a doctor who is using a new painkiller, or adjusting painkiller dosages, or using particularly strong painkillers (like the synthetic narcotic, Dilaudid), to monitor the patient for adverse reactions before sending the patient home, and, just as importantly, to inform the patient’s family to return the patient to the emergency department if they see signs of respiratory depression (which the doctor should describe).

Many people suffer daily from chronic or even acute (sudden) episodes of pain, and their only relief is the various opioid narcotics. These drugs are generally effective and safe, but only if the doctor follows certain simple and easy precautions.

Be a smart patient and insist that they do.

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Accessing Medical Records
Posted by: William Cirignani
March 27, 2008
Topic: Consumer Rights And Medical Malpractice Reform

In an increasingly mobile society, getting and transferring medical records has become a commonplace need.Public Citizen Health Research Group, www.citizen.org/hrg, correctly points out these facts about medical records:

• You are entitled to your own medical records, though you usually have to put the request in writing and probably pay copy charges (Be aware, that these charges are usually set by state statute, and that it is not uncommon, especially when the records are requested following medical malpractice, for hospitals to erroneous charge excessive rates. So be sure to research the prices for research the prices for your state (try Googling: medical record copy costs and the name of your state)

• Others,such as insurance companies, other medical care providers, government agencies, and even your employer may gain access to your medical records. Mostly they gain this right with your consent. Typically, you will be asked to sign a medical release document granting them these rights as a condition for getting benefits.

• There are circumstances where a provider may deny you access to certain types of medical records. Generally speaking, these special types of records are protected from disclosure for public policy reasons. Examples would include: psychotherapy records, hospital incident reports, records created by the hospital for the purpose of evaluating quality of medical care, and in some circumstances records relating to “private” matters, such as acquired immune deficiency.

• Generally speaking, you are entitled to get copies of your records only; however, there may be situations where the law allows you to acquire the records of others. This includes: parents getting the records of minor children; legal (court-appointed) guardians getting the medical records of their ward; and agents such as lawyers, who have acquired the right by a valid Power of Attorney.

• While medical care providers usually keep records for it five to eight years, there is no uniform law that requires a specific time. Consequently, it is a good idea to request your records whenever you are finished using a specific hospital or doctor.

• HIPPA sets national standards for medical records privacy, but does not apply unless the provider maintains and transmits records in electronic form. If your provider does, HIPPA provides that you have the right to see, get a copy of, and amend and supplement you medical records.

• Most other issues regarding health records are governed by state law, so take the time to research what your state has to say.

Author’s note: While Public Citizen has much good to say about many things, please do not assume that CH&H agrees with everything that organization says. We do not.

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Drug Manufacturers Wake-Up And Pull OTC Cold Medications
Posted by: William Cirignani
October 25, 2007
Topic: Pediatric News

As we've blogged in this space before, cold medications should never be used with children under the age of two: they are both ineffective and dangerous. The drug-makers have finally gotten the message and pulled the drugs from the market. See, http://www.cnn.com/2007/HEALTH/10/11/infant.drugs/

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Doctor Discipline
Posted by: William Cirignani
October 25, 2007
Topic: Consumer Rights And Medical Malpractice Reform

Being injured by medical malpractice is bad when the doctor is an established, well-respected licensed doctor; but it's tragedy when he's none of those things.

In July of 2006, Jose Veizaga-Mendez, M.D., a general surgeon, voluntarily gave up his license to practice medicine in the State of Massachusetts. According to Massachusetts, Dr. Jose Veizaga-Mendez gave up his license to practice medicine for non-disciplinary reasons. See, http://www.massmedboard.org/public/discipline.shtm, page 12.

But was it really non-disciplinary?

According to public records, Dr. Jose Veizaga-Mendez's agreement to give up his license followed a complaint filed by the Board of Registration of Medicine that among other things, he provided substandard care to seven patients. Seven. You may be thinking these were technical violations, that patients weren't actually hurt. Think again. Here is a sampling of the allegations against Dr. Veizaga-Mendez:

Patient A: In May of 2003, an alleged misdiagnosis in a 48 year old man led to unnecessary surgery. This unnecessary surgery was itself allegedly done improperly leading to the need for still other surgeries. As a result of these surgeries, the patient experienced prolonged paralytic ileus, which is the inability to have a bowel movement due to paralysis of the bowel. Dr. Veizaga-Mendez conduct was alleged to be "grossly substandard."

Patient G: In January of 2000, Dr. Veizaga-Mendez undertook to repair a hiatal hernia in a 58 year-old man. It is alleged that he made a surgical error that led to the leaking of stomach contents, which in turn led to infection, sepsis and respiratory failure. It is further alleged that Dr. Veizaga-Mendez didn't recognize the problem until it was too late. Despite additional surgeries, this 58 year old man died. Veizaga-Mendez conduct was alleged to be "grossly substandard."

Now you may be asking, "What's the point?" If the doctor gave up his license didn't the system work? No, it didn't because after giving up his license in Massachusetts, Dr. Jose Veizaga-Mendez simply moved to Illinois and began doing surgeries again for the Veterans Affairs Hospital in Marion. The results were tragic.

In August of this year, the VA suspended inpatient surgeries based on an unusual increase in post-surgical deaths. According to the Chicago Tribune, VA officials reported that Dr. Jose Veizaga-Mendez was involved in at least some of the nine deaths that occurred of a six month period at the Marion facility. See, http://www.chicagotribune.com/services/newspaper/printedition/thursday/metro/chi-vadococt18,2,6953971.story Our law firm has been hired by several families of patient's injured by Dr. Veizaga-Mendez. Following the shut-down of the Marion VA, Dr. Jose Veizaga-Mendez voluntarily gave up his Illinois Medical License.

It should have never come to this.

As my partner Stan Heller told the Tribune, "If one state . . . thinks somebody is not qualified to practice . . . other states ought to require the doctor to show that he is qualified, instead of the other way around."

Here's your takeaway: research your doctor! If there are complaints against your doctor, ask him or her about them. Don't submit to their care unless and until you are satisfied.

Most states have free searchable web sites for discipline against doctors. See, for example, http://www.dpr.state.il.us, for Illinois; http://www.state.ga.us/meb/bdsearch/index.htmlfor Georgia; and http://www.azmdboard.orgfor Arizona. See also, http://www.docinfo.org which is a fee-based service.

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How Doctors Think
Posted by: William Cirignani
August 21, 2007
Topic: Medical Error: Misdiagnosis

We’ve noted before (http://www.cirignani.com/PracticeAreas/Missed-Diagnoses.asp) that mis-diagnosis is almost always a product of the failure of doctors to rigorously apply the differential diagnosis method taught in medical school.  A new book offers supporting evidence of our experince.  "How Doctors Think," by Jerome Groopman, M.D. uses many illustrations to make the point that mistakes come from “thinking” errors, assumptions rather than facts about diagnosis.  Here’s how the author puts it: “Cogent medical judgments meld first impressions — gestalt — with deliberate analysis. This requires time, perhaps the rarest commodity in a healthcare system that clocks appointments in minutes.”  By sharing how doctors think, the author gives us, the patients, tools in how to help our doctors get it right.  Check it out: http://www.amazon.com/How-Doctors-Think-Jerome-Groopman/dp/0618610030

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Why Doctors Don?t Disclose Errors: It Isn?t Fear of Medical Malpractice Suits
Posted by: William Cirignani
August 21, 2007
Topic: Consumer Rights And Medical Malpractice Reform

According to two studies published in the Archives of Internal Medicine, doctors’ hesitation to self-report their errors is not related to fear of law suits. The studies compared the rate of disclosure between Canadian doctors (who get serious protections from law suits) with the disclosure rates of doctors in the United States. The comparison showed no difference. “The external malpractice environment doesn’t have the impact on doctors’ attitudes about disclosure that we thought it did,” said one of the studie’s authors, Thomas Gallagher, an associate professor of Washington School of Medicine.

(Choosing Your Words Carefully: How Physicians Would Disclose Harmful Medical Errors to Patients and U.S. and Canadian Physician’s Attitudes and Experiences Regarding Disclosing Errors to Patients, available for purchase at; http://archinte.ama-asn.org/content/vol166/issue15/index.dtl)

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The Problem Of The Shortage of Doctors
Posted by: William Cirignani
August 21, 2007
Topic: Consumer Rights And Medical Malpractice Reform

Doctor shortage is real.  The reasons for the shortage are in dispute.  The Journal of the American Medical Association recently published the findings of a new study that brings fresh light on the issue.  The study identified policies instituted in the mid-nineties by the medical community as the main culprit of shortages.  Based on faulty predictions regarding general and aging population growth, the medical community recommended freezes on on medical school slots, caps on residency slots, and cuts in residency funding.

(Looming Shortage of Physicians Rasies Concern About Access To Care, available for purchase at: http://jama.ama-assn.org/cgi/content/full/297/10/1045)

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Is The Cerebral Palsy Research Rigged?
Posted by: William Cirignani
August 21, 2007
Topic: Birth News (Obstetrics)

(This is a re-print from another topic in this blog -- Medical Research)

I ask whether political (or cultural) considerations influence scientific research at the scientist level; that is, is the person or group doing the research slanting their data or conclusions to fit a particular personal bias or agenda. Even more specifically I want to ask: In the area of medicine are there scientists whose bias is influencing the direction of their research? In the area of cerebral palsy (www.cirignani.com/PracticeAreas/Cerebral-Palsy.asp) the answer seems to be yes.

Cerebral palsy is a term used to describe brain damage in babies found at birth or shortly thereafter. About one third of cerebral palsy is preventable and is caused by not enough oxygen getting to the baby during the labor or delivery process. Yet, there is a group of doctors promoting the view that asphyxia (lack of oxygen) during the labor and delivery process rarely causes cerebral palsy. This group is called: The American College of Obstetricians and Gynecologists, or ACOG.

ACOG's history is marked by tireless and consistent efforts to promote through the medical literature and specifically for use in medical malpractice cases their position that cerebral palsy rarely arises by preventable causes, thereby excusing even the most negligent care of their members. They try to prevent cerebral palsy malpractice lawsuits by creating a very rigid set of criteria for birth injury due to asphyxia and claim that only cases meeting every one of the criteria are truly birth-related cerebral palsy cases. In fact, even if a child meets every one of these criteria, except one, they'll claim the injury wasn't due to birth asphyxia.

These hurdles are tall ones and given ACOG's political motivation the question is whether their science is true or whether the conclusion is driven by their bias of eliminating liability for their members and the companies that insure them. This is not an academic question. False and biased conclusions not only impact babies already born with cerebral palsy (whose families are trying to recover damages to help care for these children) but perhaps more tragically it impacts the quality of medicine going forward - preventable injuries will not be prevented. So, is the ACOG literature reliable?

First, you may be surprised to learn that obstetricians are notthe doctors involved in resuscitating or intubating asphyxiated newborns, nor are they the ones who test, diagnose or treat babies born with brain injuries or the complications of brain injuries. Instead, it is the pediatric neurologists, pediatric neuro-radiologists, neonatalogists and others like them whose research, data and methods focus on the timing and causes of brain damage in newborns.

Second, this research, and there is a lot of it from all around the world, (email us for citations: info@medsuit.com) directly contradicts the obstetricians' claims that cerebral palsy is rare and that in the vast majority of such cases the damage occurs before labor and delivery. One study (author: Francis Cowan), for example, looked at 351 cases of newborns with signs of brain injury within 72 hours of birth to see if there was a link between the injury and events during the labor and delivery process and found a link in almost 90% of the cases! Other studies had similar findings.

Third, another group of studies looked at whether the asphyxia that occurred during the intrapartum period (during labor and delivery) was observable and preventable. For example, in one study (author: Hakan Noren) the author looked at 29 babies born with evidence of asphyxic brain injuries and discovered that in 22 of those cases, there were abnormal fetal heart rate patterns long associated with hypoxic insult (lack of oxygen getting to baby) meaning that the oxygen deprivation was discoverable. Even more troublesome, though, was the study's finding that in many of the 22 cases appropriate medical intervention was either delayed or not given at all despite the abnormal patterns.

Here are the points: First, ACOG's "scientific" position that cerebral palsy is rare and rarely caused by preventable conditions is self-serving and untrustworthy. It is bad science generated by bias; second, every mom and dad should expect their obstetrician to know the realliterature (not the propaganda) and to be ready to intervene should evidence of oxygen deprivation show up during labor and delivery. It is the least they can do.

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Medicare To Stop Paying When Hospitals Cause Injury
Posted by: William Cirignani
July 07, 2007
Topic: Hospital News

Medicare wants to stop paying for avoidable injuries in hospitals and several major private insurance companies are expected to follow the lead.  Denying payment for such injuries (listed below) will raise a red flag for patients, letting them know that at least some of the hospitalization came from hospital error.  The avoidable injuries being targeted include:

1.     Catheter-associated urinary tract infections.

2.     Bed sores.

3.     Objects left in after surgery.

4.     Air embolism, or bubbles, in bloodstream from injection.

5.     Patients given incompatible blood type.

6.     Bloodstream staph infection.

7.     Ventilator-associated pneumonia.

8.     Vascular-catheter-associated infection.

9.     Gastrointestinal infections.

10.     Drug-resistant staph infection.

11.     Surgical site infections.

12.     Wrong surgery.

13.     Falls

The proposed regulations are open for comment and are planned to take effect in October 2008. (www.medlaw.com, May 30, 2007)

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Leading Conservative Activist Seeks Punitive Damages
Posted by: William Cirignani
July 07, 2007
Topic: Consumer Rights And Medical Malpractice Reform

Judge Robert Bork, one of the fathers of the modern judicial conservative movement whose nomination to the Supreme Court was rejected by the Senate, is seeking $1,000,000 in compensatory damages, plus punitive damages, after he slipped and fell at the Yale Club of New York City. Judge Bork was scheduled to give a speech at the club, but he fell when mounting the dais and injured his head and left leg. He alleges that the Yale Club is liable for the $1million plus punitive damages because they “wantonly, willfully, and recklessly” failed to provide staging which he could climb safely. Judge Bork has been a leading advocate of restricting plaintiffs’ ability to recover through tort law.   (June 8, 2007)

Why blog this news piece? Because it points out how, often, reformers want reform for everyone other than themselves -- WAC

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