Not only to linebackers: Undiagnosed brain injuries

Last night, ABC broadcast the moving story of journalist Bob Woodruff’s miraculous recovery from a severe head injury from an improvised explosive device in Iraq. Woodruff’s program warned that many soldiers have invisible, undiagnosed head injuries due to the concussions they suffer in explosions.

This tragic war is disturbing enough, as are the heart-breaking images of our wounded soldiers. Adding insult to the injury is the frequent failure to diagnose their head injuries, and once diagnosed, the failure to provide adequate treatment.

Mr. Woodruff illustrates quite graphically that some veterans are sent home to recuperate in smaller cities that do not have veterans’ hospitals equipped to handle the growing number of those returning with severe traumatic injuries. He interviews a young soldier who is slowly but steadily recovering at a state-of-the-art veterans’ polytrauma rehabilitation center in Tampa, Fla., then checks in on him weeks later in his hometown in Texas, where he has noticeably regressed.

Others are not even diagnosed. One solider in the story mentioned the frequent memory lapses he attributes to undiagnosed head injuries in Iraq.
Researchers screening returning soldiers and Marines at four military bases found that about 20% of troops in front-line infantry units had suffered such injuries.

"This blast group is going to be potentially huge," says Angela Drake, a neuropsychologist with the Defense and Veterans Brain Injury Center, a research arm of the Department of Veterans Affairs and the Pentagon. "We're looking at thousands of potential patients." Military doctors describe brain injuries as a signature wound of these wars. That's because advances in body armor save soldiers who might have died in previous conflicts, but blast waves from roadside bombs can cause brain damage. U.S. troops in Iraq are exposed to hundreds of bombings each month. "We've seen patients who have had three deployments and have had some (head) injury on every single one," Drake says.

The damage from multiple concussions can be irreversible. "Repeated concussions can be quite serious and even lethal," says Air Force Maj. Gerald Grant, a neurosurgeon who treated troops in Iraq.

Eight months ago, Pentagon health official Michael Kilpatrick said “in a few months,” combat medics could start using a simple mental exam to show evidence of concussions. The time is now.

Recent news reports describe the many concussions suffered by Tedy Johnson, a former linebacker with the New England Patriots. Undiagnosed brain injuries occur to the rich and famous, and also to our young soldiers who get very little respect, pay and fame. Not just to linebackers.

Read another of our stories about veterans, or read the source articles by Alessandra Stanley in the New York Times yesterday and by Gregg Zoroya in USA Today.

Warning on antidepressant and antipsychotic drugs: Drug-drug interaction

A 45-year old man from Boston had been taking four drugs for depression when he had ankle surgery in December. When the anesthetic wore off, he was given Fentanyl in the recovery room. He suddenly developed tremors and violent shaking, and started cracking his teeth, according to his wife. Moved to the Intensive Care Unit, he thrashed and flailed, oblivious to those around him, and had to be restrained physically. Two weeks later, he was still in intensive care, very confused, well after his drugs had been discontinued. The same “serotonin syndrome” had caused the death of Libby Zion in 1984.

At especially high risk of such serotonin poisoning are patients on combinations of antidepressant drugs and antipsychotic drugs that are sometimes prescribed to treat resistant depression. It can result from a combination of an SSRI (Selective Serotonin Reuptake Inhibitor, like Zoloft, Prozac, or Paxil) or an MAOI (Monoamine Oxidase Inhibitor, like Marplan, Nardil, and Eldepryl, and another serotonin-raising substance.

Advice to patients taking these drugs: Ask your pharmacist and doctor about possible drug-drug interactions.

Read another of
our stories of a drug-drug interaction, or the blog post of Dr. R. W. Donnell, Jane Brody’s story in today’s NY Times, “A Mix of Medicines that can be Lethal,” and the review article in the New England Journal of Medicine.

Hospitals are testing patients’ patience on infection rates

I salute CEO Paul Levy’s courage and visionary leadership in posting Beth Israel Deaconess Medical Center’s infection rates on his blog. Every patient wants hospitals to compete on quality, not just cost—which hospitals fear, and block.

Critics who cite measurement problems in comparing different hospitals' infection rates are both correct and highly distracting. Legislation filed by Sen. Moore and Rep. Denise Provost and 45 co-sponsors, and backed by even more legislators, would require that all Massachusetts hospitals publicly report their infection rates, on a common yardstick. We’ve run out of patience, as the legislators know.

An executive in a nearby large hospital system contemptuously commented about his competitor's blog post, “What’s a blog?!” We patients know serious errors occur daily, and through blogs like PatientSafetyBlog.com we are getting smarter about where and how to get the best care. Hospital leaders might want to read the stories of medical errors that we’re learning and telling each other.

Read Liz Kowalczyk's column in the Feb. 23 Boston Globe...

He probably saved my life: A patient advocate

Retired Probate Court Judge Sumner Kaplan was hospitalized for life-threatening colon cancer. A long-time retiree friend—a former physician named Jonathan Fine—visited and even stayed with him in the hospital, sleeping on the floor. Dr. Fine (yes, that’s his real name) clarified the explanations of Sumner’s doctors, fetched ice water, helped Sumner walk the halls, eased his anxieties about dying, and pressed for a CT scan that uncovered an internal bleed (hemorrhage) that could have killed Sumner.

“He probably saved my life…He gave me not only a feeling of comfort, but of hope,” judged Kaplan.

Advice: Get an advocate for your hospital stay.

Read another story of an advocate friend, or read the article by Alice Dembner in today’s Boston Globe.

Cheatum was cheated: A nursing home lawsuit

This week the family of a Tennessee man won $4 million in a lawsuit against the nursing home chain that had cared for him. Cheatum Myers suffered numerous falls during his nursing home stay, one of which broke his hip. He didn’t get treatment for the injury for a week.

 And an infection around where Myers’ catheter was located led to a high fever complicated by pneumonia. He had one bedsore all the way to the bone on his heel.

 Mr. Myers died in 2005, and the lawsuit claimed it was because of the lack of care.

Advice to the adult children of frail elders: Check the quality ratings of nursing homes with your state’s department of public health.

Read another lawsuit story, or read the source story in the Daily News Journal.

Her doctor’s survey led to a discussion: Partnering with your doctor

Our problems can be complicated, but doctors’ appointments are short. Often important complaints don’t even get mentioned. As a solution, some doctors use a ten-minute web survey, “How’s Your Health,” developed by Dr. John Wasson of Dartmouth Medical School. The survey leads many patients to indicate, up-front, signs of trouble that they often wouldn’t discuss during the short face-to-face visit. The answers form a snapshot that gives the doctor a head start before the patient sets foot in the doctor’s office.

About a year ago, Susan Arazy filled out a survey, and scheduled an appointment for a sore throat. Her primary care doctor saw on her latest health snapshot from the survey that she wasn’t following a healthy diet or exercising enough. This was especially important because of her diabetes. The snapshot triggered a discussion with her doctor of her lifestyle and habits, prompting her to join Weight Watchers and lose 35 pounds.

Advice for patients looking for a new primary care provider: Ask whether the doctor uses the survey or other electronic methods so that the limited appointment time with you will be most helpful to you.

Read about another diabetes patient story, or read Gautam Naik’s article in today’s Wall Street Journal.

Warning on ADHD Drugs: Adverse drug reactions

Yesterday, U.S. government health officials ordered the makers of drugs for Attention Deficit Disorder (ADHD) to write Patient Medication Guides to alert patients about the drugs’ adverse effects on patients’ hearts and brains. ADHD affects 5% of school-age children and almost as many adults, and use of these drugs by adults has more than doubled since 2000. The drugs include Adderall, Concerta, Daytrana, Desoxyn, Dexedrine, Focalin, Metadate CD, Methylin, Ritalin, and Strattera.

Advice to people taking drugs for ADHD: Read the FDA press release and draft medication guides. Work with your physician to develop a treatment plan that includes a careful health history and evaluation of current status, particularly for cardiovascular and psychiatric problems (including assessment for a family history of such problems).

Maybe an early warning about a man's heart disease: Missed diagnoses

Half the people who die of heart disease die suddenly, undiagnosed. Surprisingly, impotence may be an early warning sign of a man’s undiagnosed heart disease. Some experts say what we are seeing in all the use of Viagra, Cialis, etc., is not so much an impotence epidemic as an explosion in the number of men suffering from other conditions - cardiac disease, diabetes, and metabolic syndrome - which include impotence as one of their symptoms. A recent study by Prof. Michael Kirby at the University of Hertfordshire found a strong link between impotence and heart disease. Erectile dysfunction can be a valuable warning sign, giving a sufferer time to make life-saving changes, before he has a heart attack.

Advice to men about impotence: Ask your doctor about this. The ocean is full of fish, and the doctor’s advice may give you extra years to enjoy using your rod and reel.

Read about how women can prevent heart disease, or read the source story by Victoria Lambert.

Women, Keep your heart open, continued: Preventing heart disease

News you can use for women over 65: Ask your doctor whether taking a baby aspirin each day would reduce your risk of having a stroke and heart attack. That’s the latest guideline of the American Heart Association, published yesterday and backed by numerous studies.

An aspirin a day might keep the heart surgeon away…and if not, read the blog story on the surgical solution of stenting open narrowed heart arteries.

Jay Leno’s Advice

"In an interview with USA Today, Senator Barack Obama says the shortness of his political resume is his greatest strength. Politics is the only business where people brag about how little experience they have. Can you imagine guys saying to you: “Look, I’ve never been to medical school, I’ve never even watched 'E.R.,' but if you just let me try and do this brain operation I’ll do the best job I can.”?"

(Quoted in the New York Times yesterday.)

They dismissed her concerns: A misdiagnosis story

A ten-year-old disabled girl has died in the hospital amid claims that doctors misdiagnosed her condition.

Ayesha Wyatt died in Alder Hey Children's Hospital in Liverpool in the early hours of Tuesday morning with her mother at her bedside.

Ayesha’s mother claims that doctors dismissed her concerns that a plastic shunt removing harmful fluids from her daughter's brain had become blocked when the child's neck swelled up last month.

Advice to parents: You know your child better than anyone; you are their primary care provider. Keep the courage of your convictions when you see medical professionals disregard a key sign about your child. Go to a higher authority in the hospital if you think the doctors and nurses are making a serious mistake.

Read Darren Devine’s article, or read a story of a family advocate with a happy ending.

Her care in the nursing home was better: A hip story

Here's a 4-minute video of an NBC Special Report about a hospital's care of an elderly Connecticut woman, initially hospitalized for a broken hip. (The video may take a few minutes to load.)

Advice to sons & daughters of elderly parents: Get an advocate when your elderly parent has to enter the hospital. An advocate can detect this in time to save your mother or father.

Keep an open heart! –Don’t stint on your post-stent meds, continued: Preventing heart disease

If you have a friend who has had a stent slid into a heart artery to keep it open, pass this on to them. The newest consensus of medical opinion is for people with drug-eluting (emitting) stents to take daily doses of aspirin and Plavix for a year to reduce the risk of blood clotting in the artery. The recommendation appears in the prestigious New England Journal of Medicine last week, and updates January’s blog post.

Advice: Have your friend discuss this with their doctor.

Read Barnaby Feder’s article in the NY Times, Feb. 13, page C3.

But the magazine said he was a Super Doctor: An overdose lawsuit

The cancer doctor’s web site touts the fact that he was named in Texas Monthly as a so-called “Super Doctor" in December, 2005. But earlier that year he had lost the biggest malpractice suit in the county’s history--$600 million!--and a month later, another patient died from a chemo overdose under his care.

How does a physician become a Texas Monthly “Super Doctor?” Or for that matter, a Best Doctor for D Magazine?

“Super Doctors” is actually the trademark of Minneapolis-based Key Professional Media, which has made a business of publishing “Super” lists. Key Media is secretive about how its “Super Doctors” are chosen, and would not disclose how many doctors vote, saying that number is “proprietary.” Every voter can vote as many as ten times. Lorelei Calvert of Texas Monthly says Key basically buys a section of the magazine, labels it a “special advertising section” and sells the advertising space to doctors.

D Magazine asks “Which Dallas Doctors would you trust to send your loved ones to for medical care?” Rogers says the D survey is announced to hospital PR staffs before it is mailed to doctors. This allows them to stump for votes among their own staffs. Each surveyed doctor could cast as many as 117 votes over 39 different specialties. D says it got about 25,000 responses from 1,014 doctors, and selected 640 people as “Best Doctors.” Doctors are offered the chance to buy an ad in D Magazine to “maximize their exposure” when they’re notified they’ve been chosen as a “Best Doctor.” It is the best selling issue of the year.

Advice on finding a super doctor: Start by checking the profile yourself, if you can. In Massachusetts, you should first look them up in the Board of Registration in Medicine’s web site.

Read the article by Byron Harris.

“The biggest mistake of my life”: A gastric bypass surgery lawsuit

He now suffers great pain while standing on the sidelines, coaching football—but he was at death’s door, and he’s alive—and in court, suing his surgeons. His 350-pound bulk had hurt his chances of becoming a head coach—and risked an early death. So, after talking with doctors at a Harvard teaching hospital, Charlie Weis, the former offensive coach for the New England Patriots football team, agreed to gastric bypass surgery.

The surgical staples that sectioned off a small part of his stomach had not been tight enough to prevent leaks, and internal bleeding was filling his abdomen and compressing his lungs. It took his doctors and nurses almost two days to discover the bleeding. “He spent days at death’s door,” according to his lawyer, and spent three weeks in the hospital. He has suffered permanent nerve damage to his right foot that makes it difficult to walk and stand. Weis calls the surgery “the biggest mistake of my life.”

Advice: Surgery is inherently dangerous; keep that in mind when considering optional surgery. Find out your alternatives by getting a second opinion—from a doctor who is not a surgeon.

Read about another gastric bypass patient, or read Scott Allen’s article in today’s Boston Globe.

Rx’s for Doctors

Internists: Good News on Cancer described the recent reductions in cancer rates, especially because of colorectal screening. As you know, patients approaching age 50 have several options for colorectal screening.

Advice for internists who use paper charts: Have the receptionist identify each morning which of the day’s patients are nearing age 50. Have them place a PostIt note with a picture of a colon or pair of buttocks onto the front of the chart. That will give you a memorable, cheap, and confidential reminder to discuss options for colorectal screening with that patient, and you’ll start the discussion with a smile.


Oncologists: Now A Model Patient describes a cancer patient’s non-compliance with an outpatient oral chemotherapy order. It draws on this month’s article in the British Medical Journal by Dr. Saul Weingart et al. They found that two-thirds of the cancer centers in the U.S. write chemotherapy orders without writing the patient’s body surface area.

Advice for oncologists: If you hand-write oral chemo orders, make a special pre-printed form that has a space explicitly for the body surface area. That will prompt you to record it, giving the pharmacist a convenient way to verify that he or she is not dispensing an overdose.

Oncologists: Weingart’s survey found that “few” cancer centers get patients’ written informed consent for off-protocol oral chemotherapy drugs. This may well expose you to a risk of a lawsuit, and foregoes an opportunity to learn and honor the patient’s wishes.

Advice for oncologists: Have patients sign a consent form for off-protocol prescriptions.


Family Medicine physicians: Lucio Satar’s parents didn’t immunize him against the flu, and Lucio developed pneumonia, with complications, and died.

Advice: Please suggest to the families you see in the next few weeks that they get vaccinated.

Overdoses – the Numbers

Unintentional fatal drug overdoses in the United States nearly doubled from 1999 to 2004, and are now the nation's second-leading cause of accidental death, behind automobile crashes, the Centers for Disease Control and Prevention reported recently.
Nearly 20,000 people died from accidental drug overdoses in 2004, according to death certificates. CDC researchers believe sedatives and prescription painkillers such as Vicodin and OxyContin were the chief cause of the increase.

"There is a misperception that because a drug is a prescription medicine, it's safe to use for non-medical reasons. Clearly that is not true," said Dr. Anne Marie McKenzie-Brown, a pain medicine expert at Atlanta's Emory Crawford Long Hospital.

Advice: When you’re done with your Vicodin or OxyContin prescription, toss them down the garbage disposal; you can get another prescription if and when you need it.

Read Mike Stobbe’s full newspaper article.

Parkinson’s Treatment - Off and On: A medication error

Raul, a very nice elderly man who has had Parkinson’s Disease for 15 years, had frozen in place, seemingly awake but unresponsive, for more than an hour. Such on/off states among Parkinson’s patients are quite frightening to spouses when they occur. They seem to occur when the patient’s brain lacks Dopamine, a chemical that is provided by Sinemet. Alarmed, his wife called an ambulance, which took Raul to a large, well-known medical center. He arrived at noon. Later that afternoon, his wife gave his Sinemet—the mainstay of his treatment for all these years—to the E.R. nurse, with instructions that his next pill was due at 11 pm.

Raul was finally admitted to a hospital bed on the Surgery unit at 9 pm, because no bed in an appropriate unit was available. When Raul’s adult son called Raul’s nurse at 11:40 pm to verify the nurse had indeed given him the Sinemet, the nurse said another nurse was getting it. In other words, the attending physician had to write an order for the same medicine, hopefully in the same dose, with a similar timed release, and the hospital Pharmacy would dispense it—but this had not been done, and the dose was already 40 minutes late. Without their Sinemet, patients with advanced Parkinson’s often have extreme, uncontrollable tremors affecting their whole arms and legs, as viewers of Michael J. Fox’s political advertisement in last year’s Senatorial election in Missouri saw. The nurse mentioned that Raul had been quite “restless.” As my teenager says, Duh!

The hospital’s delay in providing the Sinemet had both caused this upsetting and uncomfortable set of tremors, AND made a recurrence of the on/off state even more likely—and that was the very cause that brought him to the hospital for treatment! Excuse my cynicism, but I doubt that the hospital will withhold their bill, or delay in sending it. Raul’s Medicare should cover the bill, so my thanks to you, Reader, the American taxpayer, for paying for his care

Advice to patient advocates: If a hospital patient depends on the meds he has brought from home, call to ensure that nurses have given them to him on time.

I Confess! Now Tell the World: Medication error reporting

Makers of electronic incident reporting systems tout the efficiency of the electronic reporting of medical errors. Yes, paper can be inefficient--that's part of the ugly beauty of it. Nurses and doctors already are reluctant to formally report their errors, often with good reason, and currently do not report the vast majority of medical errors. How many of them would suddenly choose to report their tragic mistakes electronically, when that becomes possible?!

A Celebrity Mom--A Dangerous Mix: Anna Nicole Smith

Anna Nicole Smith, may she rest in peace, bore a son Dan in 1986. Dan Smith had died suddenly in the Bahamas in September, while visiting his mother and her new baby girl, Dannielynn. A medical examiner recently determined that Dan's death was due to an interaction of methadone and anti-depressants.

Advice to patients on several drugs: Check this web site by ExpressScripts to learn if your medicines have potentially dangerous drug-drug interactions.

Read another drug interaction story, or read today's NY Times article by Abby Goodnough and Margalit Fox.

Now, a Model Patient: Partnering with your doctor

Velda Model had had surgery—twice—to remove a tumor from her breast. Then she endured chemotherapy that made her fingers and toes numb, and radiation that made her tired all the time. She was given Aromasin pills to prevent the cancer from coming back, but they made her body ache, and her heart race. So she stopped taking them, saying “I can’t live like this.” Her cancer doctor (an oncologist) eventually convinced her that the hormone’s benefits outweighed the discomfort.

Now she contacts the doctor’s office when she experiences severe side effects, allowing the doctor to discuss alternatives. She has been able to reduce the flu-like symptoms of the hormone treatment by taking the pills after dinner rather than before dinner.

That partnership between the patient and physician is our goal. In her case, that’s especially important, because women with hormone-responsive early breast cancer who do not take five years of hormone therapy pills increase their risk of recurrence by 50%.

Advice to patients with side effects from drugs: Tell your doctor, and explore alternatives with him or her.

Read Sunday’s Boston Globe article by Scott Allen, or the full study by my buddy Dr. Saul Weingart et al in the British Medical Journal.

2 news shows on patient safety

1. The CBS Evening News with Katie Couric will feature a segment about health care quality, with a focus on Don Berwick, the Institute for Healthcare Improvement, and IHI's 5 Million Lives Campaign. The program also touches specifically on infection reduction efforts at Beth Israel Medical Center in New York City, led by BIMC’s Director of Infection Control, Dr. Brian Koll. The segment airs Tuesday, February 6th at 6:30 PM Eastern Time.

2. The CBS Early Show is doing a segment on disclosure and apology on Wednesday morning, February 7th. Linda Kenney and Dr. Rick Van Pelt of
Medically Induced Trauma Support Services (MITSS) were interviewed on Friday, but I don’t know what the final piece will look like. I believe that the show runs on Channel 4 from 7 to 9 in the Boston area; be sure to check your local listings.


Thanks to James Madden and IHI for spotting this.

Nobody was there to assist them: Dialysis errors

The chief medical examiner of Maryland has identified 24 kidney dialysis patients who bled to death, usually at home alone. And the Mid-Atlantic Renal Coalition, which oversees kidney programs in three states and the District of Columbia, knows of even more cases.

In dialysis, a life-saving treatment for kidney disease, a patient's blood is cycled through a machine that removes impurities and waste products. In most cases, doctors tap a vein in the arm or leg, creating a "vascular access site" or portal that can be used for years. Most of the people died after their access sites weakened from repeated use and finally leaked.

"Most of these people seemed to be alone at the time the bleeding occurred," the Medical Examiner said in an interview. "Nobody was there to assist them."

Dr. Jeffrey Fink, former chairman of the Maryland Kidney Commission, said he has never had a patient bleed to death, though one recently woke up in time to get help. "The patient had a hemorrhage and happened to wake up wet," he said. "Everybody I talked to has a few cases where this has happened."

Advice to dialysis patients: Get a friend or family member to check on you during dialysis, if possible. And get educational sessions about the proper care of your access sites and the signs of trouble.

Read another kidney story, or see Jonathan Bor’s article in the Baltimore Sun. Thanks to Helen Haskell for spotting this.

Lucio Satar: A flu vaccine story

Lucio Satar, a healthy eight-year-old boy in Minnesota, began feeling sick with the flu on Jan. 24. He died Wednesday of pneumonia, a complication from the flu.

Across the U.S., about 100 children die every year from flu complications, according to Patsy Stinchfield, a pediatric nurse practitioner who leads the Minnesota Immunization Practices Advisory Committee.

Advice to parents: Please have your families vaccinated against the flu.

Read the story in the Lacrosse Tribune.

Just kids having fun?: Wrong drug errors

A month ago, in a blog post here, I advised parents to discard unused meds to keep teenagers safe. Here’s a news story about middle school students in Texas that shows why that’s important.

It turned out to be a few dozen: A misdiagnosis

Dr. H was working in the emergency room of a hospital on a Navajo reservation. Dozens of people had recently come to the hospital suffering from viral pneumonia. Blanche Begaye (a pseudonym), a Navajo woman in her sixties, came to the emergency room because she was having trouble breathing. She is a compact woman with long gray hair, worn in a bun. She told the doctor that she had begun to feel unwell a few days earlier. Thinking she had a bad cold, she had drunk orange juice and tea, and taken a few aspirin. Now her symptoms had worsened. She now had a slight fever, and was breathing at almost twice the normal rate. Her lungs sounded clear. A chest X-ray and a lab test of her white blood cell count made the flu or pneumonia unlikely.

However, her blood had become slightly acidic, which can occur in the case of a major infection. The doctor told Blanche that he thought she had “subclinical pneumonia”—an early stage of the infection, as the virus had not yet affected her lungs in a way that would show up on the chest X-ray. He ordered her to be admitted to the hospital.

A few minutes later, another doctor discovered that Blanche actually had aspirin poisoning. She was an absolutely classic case—the rapid breathing, the shift in her blood electrolytes.

Dr. H. had misdiagnosed her because the widespread viral pneumonia he had been seeing was uppermost in his mind. Rather than try to integrate all the information he had about her illness, he had focused on the symptoms that she shared with other patients he had seen: her fever, her rapid breathing, and the acidity of her blood. He dismissed the data that contradicted his diagnosis.

When he had asked whether she had taken any medication, including over-the-counter drugs, she had replied, “A few aspirin.” Dr. H. explained, “I didn’t define with her what ‘a few’ meant.” It turned out to be several dozen.

Advice for patients and advocates: Prepare a summary of your symptoms for the doctor, and be specific. If Blanche had specified the number of aspirin she had taken, she would have made it much easier for the doctor to diagnose. The doctor is on your team; treat him that way, and help him do right by you.

Read another story of a preventable adverse reaction, or read Dr. Groopman’s article in the New Yorker.