About Dr. Gustin
Dr. Gustin is residency-trained and board-certified in Emergency Medicine and Forensic Medicine and has been actively practicing in the fields of Emergency Medicine, Toxicology, and Forensic Medicine for more than 30 years. He has additional training and expertise in Medical, Occupational, and Environmental Toxicology and has Masters Degrees in Biochemistry, Metabolism and Nutrition, as well as Toxicology and Public Health. He is the primary founder of the American College of Forensic Medicine which currently has more than 2,000 members.
Dr. Gustin has reviewed thousands of medical malpractice, personal injury, criminal, and toxicology cases during his career. Dr. Gustin also has substantial testimony experience as an expert witness.
You can access Dr. Gustin's medical-legal experience by requesting a FREE phone or email consultation now. To review all the Services he offers, please click here.
Dr. Gustin's education, training, and experience qualifies him to evaluate and testify regarding a broad range of cases, in the following medical and toxicology specialty areas:
- Emergency Medicine, medical, surgical, pediatric
- Emergency Medical Ambulance Services (EMS)
- Trauma and Critical Care
- Forensic Toxicology
- Medical Toxicology and Poisoning (eg: accidental overdose, carbon monoxide poisoning, and all other product and drug exposures)
- Occupational and Environmental Toxicology
- Mechanisms and Forces of Injury in Criminal Cases
- Substance Abuse and Drug Addiction (Drug and Alcohol, including DUI)
- Electrical Injury
- Pharmaceutical Medicine (Drug-Drug interactions, Drug-Disease Interactions, Overdose, Unsafe poorly tested Drugs, Adverse Drug Reactions)
- Flight, Travel, and Wilderness Medicine
- Hospital Malpractice
- Public Health (eg: Legionnaire's Disease, Outbreak Diseases, Food Poisoning, and Waterborne Diseases)
- Legal Medicine (standard of care, evidence-based causation, medical ethics)
His primary areas of specialization are Emergency Medicine and Toxicology.
A partial list of cases Dr. Gustin has consulted on include: drugs of abuse including Methamphetamine, Cocaine, Opiates, Ambien,and Alcohol, occupational chemical poisonings including toluene, benzene, isocyanates, other solvents, heavy metals including lead, carbon monoxide, and cyanide, occupational and travel-related infectious illness including Legionnaire's disease, MRSA, skin infections, bacterial enteritis, misdiagnosis and delayed treatments in the ER, civil rights cases, environmental exposure cases including contaminated water and sewage exposure.
Dr. Gustin's expert opinions will comply with ACEP (American College of Emergency Physicians) guidelines for Expert Witness Testimony: See: http://www.acep.org/practres.aspx?id=29446 ; the ACT (American College of Toxicology); and ACFE (American College of Forensic Examiners) Creed of Ethics. See: http://www.acfei.com/about_acfei/creed/
Office: 2928 Derby Street, Berkeley, CA 94705
Email: Click here to email Dr. Gustin
LEGAL LSD: a new dangerous hallucinogen
A novel psychoactive substance, or "legal high," that has hallucinogenic effects and potentially severe adverse effects is being sold to partygoers as lysergic acid diethylamide (LSD).
Although the use of 25I-NBOMe, also known as "legal LSD," is currently relatively rare, it is sold under various names and in a range of forms, making it difficult for users to know what they are taking and for clinicians to develop effective treatments.
Rising Tide of Novel Psychoactives
The most commonly seen novel psychoactive substances are synthetic cannabinoids and synthetic cathinones, as well as the novel phenethylamine 25I-NBOMe, or 4-iodo-2,5- dimethoxyphenyl-N-(2-methoxybenzyl) phenylamine.
25I-NBOMe, or 4-iodo-2,5- dimethoxyphenyl-N-(2-methoxybenzyl) phenylamine was first synthesized for research on the serotonin-2a receptor. It became popular as a recreational drug in 2011. It is sold online as legal LSD or LSD, and is ingested orally or sublingually, typically on blotting paper.
Typical doses are 0.5 to 1 mg. Peak effects, which include hallucinations and euphoria, occur after 20 minutes and last for 3 to 13 hours. Several cases of toxicity with 25I-NBOMe have been reported, along with adverse effects such as delirium, aggressive behavior, self-harm, and paranoia.
Dr Ezquiaga and colleagues investigated the prevalence and characteristics of 25I-NBOMe in Spain by using data from Energy Control, a Spanish harm-reduction nongovernmental organization whose workers go to clubs and raves (a type of large dance party), where they offer advice to drug users and also offer to analyze whatever drugs the partygoers are taking.
Between 2009 and 2015, 21,198 samples were received by Energy Control and analyzed by gas chromatography–mass spectrometry, 56 of which were 25I-NBOMe.
Hard to Keep Up
The samples of 25I-NBOMe were first detected in 2012. The number of such samples peaked at 19 in 2013. Usage then dipped but remained stable to the end of the study period, when 15 samples were detected.
In 42.8% of cases, 25I-NBOMe was bought as LSD; in 21.4% of cases, it was bought as 25I-NBOMe; in 7.1% of cases, as 25I-NBOH; in another 7.1%, as 25C-NBOMe; and in the remaining 21.4% of cases, as other substances.
The most common form of delivery was blotting paper, found in 37.5% of cases, followed by powder form in 33.9% of samples and liquid form in 10.7%. Curiously, in 5.3% of cases, the drug was sold in gummy bears (a form of candy).
The use of novel psychoactive substances is increasing every year, but our knowledge is not growing at the same speed as their development, which means that we still don't have any urine tests to detect novel psychoactive substances, we still don't have treatments to solve the toxicity, we don't have specific treatments, and we still have a lack of information about the pharmacology.
The Internet has become the most important marketplace for these substances, a development that represents a major shift from the manner in which illicit drugs have been bought and sold in the past.
Potential Brain Damage
Highlighting the fact that a substantial proportion of individuals who bought 25I-NBOMe thought they were buying LSD and the potential implications in the future to cause damage to the brain is cause for concern.
SINGLE-PAYER System is not the Answer
Single-Payer System: Why It Would Ruin US Healthcare
Single-Payer Would Be Bad for Doctors
A single-payer system—government-run healthcare for all—sounds like a noble ideal, but things quickly fall apart in the execution, according to its critics.
Michel Accad, MD, a cardiologist in San Francisco, says that because a single-payer system makes healthcare virtually free, "demand is almost unlimited," and the government has to set limits on what will be provided. Dr Accad writes a blog called "Alert & Oriented," which provides alternative views on healthcare systems.
Because the offer is so open-ended, Dr Accad says that single-payer systems in Canada, the United Kingdom, and other developed countries have to impose strict central planning. Rather than leave healthcare choices up to individual physicians, their patients, and free-market forces that could balance supply with demand, the government sets the rules.
These rules, Dr Accad says, are usually based on large quantities of data—comparing costs against probable outcomes—or on political considerations, such as the need to balance budgets without raising taxes. This approach, he says, will inevitably misallocate services. When central planning allocates care, there will be shortages of some services and gluts of other services. In particular, central planners will have a difficult time keeping up with cutting-edge technology and improvements in practice patterns.
Centralized systems also underpay physicians. "In a single-payer system," Dr Accad says, "planners decide arbitrarily what the payments should be, and payments fall because there are no competitors and no choice for providers to bid up payments."
Indeed, a 2011 study found that reimbursements to US primary care physicians from public payers, such as Medicare and Medicaid, were 27% higher than in countries with universal coverage, and their reimbursements from private payers were 70% higher. Meanwhile, reimbursements to US specialists were 70% higher from public payers and 120% higher from private payers.
Lack of Competition Harms Doctors
Another disturbing aspect of a single-payer system is the lack of competition among payers, which would reduce physicians' control over standards of care and reimbursement.
In a pure single-payer system, doctors can only contract with the one payer available. Currently, in the United States, physicians have some choice of insurers to work with, and even in Medicare or Medicaid, doctors can opt out. But they couldn't do so in a pure single-payer system.
"Providers remain ostensibly independent, but the single payer exercises significant controls," such as determining what services are "necessary," wrote John McClaughry, founder of the Ethan Allen Institute, a free market think-tank in Montpelier, Vermont. The single payer is a "monopoly HMO," he added.
Critics say the single-payer program might start with acceptable reimbursement rates as a way to get physician buy-in, and then ratchet them down because there is no alternative. As Dr Accad has already pointed out, the single payer can reduce reimbursements with impunity, because it has a monopoly.
Rather than restrict choices further, opponents of a single-payer system want to open up choices in the current system. "We should strike down state barriers to insurers and allow their products to be sold nationally," says Jim Geddes, MD, a trauma surgeon near Denver.
Noah N. Chelliah, MD, a cardiologist in Grand Forks, North Dakota, agrees. "Auto insurance premiums are low because insurers had to compete with each other nationwide," he says. "The same could be done for health insurance."
"When physicians become essentially employees of the government, which is what happens in a single-payer system, then everything pretty much breaks down," Dr Geddes says. "Only physicians are the best position to determine the quality of care. We're the number-one patient advocates."
However, Dr Geddes does not believe that the United States would allow complete termination of commercial insurance. He thinks there would probably be private plans that people could purchase on their own, as is the case in the United Kingdom. However, "this would lead to a two-tiered system," he says. "I've seen it in the United Kingdom, and it's not what we should have here."
Waiting Lists in Canada
Canadian Medicare, administered by each province and funded through taxes, provides healthcare to all residents, with minimal out-of-pocket payments. Private healthcare is not allowed in Canada, so Canadians on long waiting lists have to go to the United States and other counties to get expeditious care.
Waiting lists are a familiar feature of single-payer systems, especially for higher-cost or cutting-edge healthcare. According to a report by the Fraser Institute, an independent think-tank in British Columbia, Canada, the median waiting time to get treatment from a specialist has doubled in the past 20 years, to 18.2 weeks. Canadian patients wait the longest for orthopedic surgery (42.2 weeks), neurosurgery (31.2 weeks), and plastic surgery (27.1 weeks).
Dr Chelliah—whose North Dakota practice is 80 miles from the Canadian border—says that many Canadian patients on waiting lists come to him and other providers in the area for care. He thinks the waiting lists are intentional. "The way I see it, the Canadian system saves money by delaying care by rationing," he says. "The net result is that people die before they finally can get their care. I know that sounds provocative, but I think it's true."
A few years ago, he noticed that a Canadian friend of his was huffing and puffing and told him he needed to get a stress test. His Canadian family physician was initially reluctant to order one but finally agreed, and then it took 3 months to get the stress test done. Even though the results were strongly positive, the man wasn't scheduled for an angiogram until the following year. The angiogram found a 99% blockage, called a "widow-maker," and he finally got a stent. "This patient could easily have died," Dr Chelliah says.
Dr Accad pointed to a recent news report from Canada, in which a leukemia patient had a bone marrow donor, but she couldn't get the transplant because there wasn't a hospital bed available for her. Though the problem sounds crazy, "patients in these systems tend to accept waiting lists," he said.
Quality Problems in the British System
In Great Britain, the National Health Service (NHS), operating separately in England, Scotland, and Wales, not only finances healthcare but also owns hospitals, physician practices, and the practices of other providers of care. However, about 10% of Britons have access to private facilities paid through private insurance.
Those who want to have expedited care buy private insurance. Dr Geddes recalls that his nephew had an anterior myocardial infarction while working in London. He was first transported to a nearby NHS hospital, but they didn't have a catheter lab to treat him, so he was sent to a catheter lab at a private hospital covered by his private insurance. "He probably would have died at an NHS hospital," Dr Geddes says.
Dr Geddes believes strict government controls and impossibly long waiting lists have created a fatalistic attitude among many British doctors, and this makes the waiting lists even longer. Many years ago, he traveled to the United Kingdom to watch a British surgeon operate. The surgery team showed up at 8:00 AM and had two cases for the day. "The first case took a little too long, and afterward we had a leisurely lunch," he says. "The second patient was an open-heart case and had already been prepped, but they decided they wouldn't have enough time." The operation was postponed. "In the United States, we would have gone ahead with the second case and just stayed late," Dr Geddes said.
Scandal at the VA: the US Version of British Healthcare
The unhurried attitude of his British colleagues reminded Dr Geddes of the time he spent as a resident at two hospitals in the Veterans Health Administration, which is part of the Department of Veterans Affairs (VA). "The VA medical staff has some good doctors, especially in VAs affiliated with universities," he says. "But as a general rule, the staff has shorter work hours. They are just punching a clock."
The VA system is as close as US healthcare comes to the British system. It operates 150 hospitals and almost 1400 outpatient clinics and provides care to 8.3 million veterans a year. Like the NHS, it also has waiting lists, which involved a scandal that rocked the VA in the spring of 2014 and caused the departures of the VA secretary and the system's top health official.
For years, the VA has set limits on how long its waiting lists can be, but the number of patients has been growing well beyond the system's capacity to deal with them. It turned out that many VA staffers were fudging waiting-list numbers so that they wouldn't exceed the limit. Dr Geddes wasn't surprised. "This is a subpar healthcare system," he says. "If we introduced a single-payer system in the United States, pretty soon it would look like the VA."
"A single-payer system is about control," Dr Geddes says. "It isn't about improving healthcare. There are many ways of doing that without involving the government. It's about the need to exercise control."
Vermont Abandons Its Single-Payer Dream
In the past few years, Vermont had been the darling of single-payer advocates. The state had been planning a system called Green Mountain Care since 2011. But suddenly, in December 2014, Governor Peter Shumlin announced that the effort would be abandoned owing to the cost.
Before the governor's announcement, Green Mountain Care was expected to make money. A 2011 report by an outside consultant predicted $590 million in savings in the first year. But to get those savings, state government would have had to take over all the operations of commercial insurers, without having any experience.
In the end, Green Mountain Care was slated to cost the state $4.3 billion in 2017—almost doubling Vermont's total budget of $4.9 billion for fiscal year 2015. This would have required a payroll tax of 11.5% and a 9% tax on income.
Vermont has not entirely given up on its single-payer dream. The state is now reportedly planning all-payer rate setting, in which it would set payments for Medicare, Medicaid, and private payers. This would be done through a unique federal waiver from the Centers for Medicare & Medicaid Services (CMS), but the state has not yet formally applied for it. If CMS granted the waiver, Vermont would be able to exercise the price-setting controls of a single-payer system without the costs of actually running the whole system.
But for now, the dream is over. A single-payer system was never a realistic goal, says David J. Weissgold, MD, a retinal surgeon in South Burlington, Vermont. "The plan was naive and foolhardy," he says. "It's the kind of sweeping change that plays well politically. It has inspired a lot of people, but it's a fantasy, a kind of a dream state. I never thought it would work."
The advocates of a single-payer system refused to face the grim reality of actually running such a system, even though it was there for all to see just across the border in Canada, says John McClaughry.
Faced with rationing in Canada, Vermont single-payer advocates said it was simply caused by "stingy taxpayers," he says. When a Vermont single-payer physician debated a Canadian physician who listed the system's failures, her reply was, "We're Vermonters; we can make it work," McClaughry recalls.
McClaughry, a former advisor to President Reagan and Vermont legislator, says that single-payer is a fundamentally flawed concept, focusing on the need for healthcare rather than on true demand. "Demand, initiated by patients who may not understand what they really need, will be replaced by government-controlled allocation of services on the basis of what patients are determined to reasonably need," he wrote in a policy brief.
Waning Enthusiasm for Single-Payer
The VA scandal and the demise of the Vermont plan were not the only defeats for a single-payer system in 2014. Activists in Colorado failed to get enough signatures to get a single-payer measure on the November ballot. And in Massachusetts, Donald Berwick, MD, the former CMS administrator who ran for governor on a single-payer platform, won only 21% of the vote in the Democratic primary.
Even in Europe, the heart of the single-payer movement, the concept has encountered embarrassing defeats. In Sweden, owing to access problems in the country's single-payer system, about 10% of residents have opted for private health insurance, according to the trade group for Swedish private insurers. And in Switzerland, almost two thirds of voters rejected a single-payer proposal.
In the United States, public opinion has been shifting away from support of "healthcare for all" ever since the build-up to President Obama's Affordable Care Act (ACA). Gallup reports that in 2000, 59% of Americans said the nation has a duty to provide healthcare for the poor. The number peaked in 2006 at 69%, but in polls since 2009, a slight majority of Americans oppose that responsibility.
Single-payer advocates are actually a subset of those calling for universal care, which includes advocates of multipayer approaches, such as the ACA. An April 2014 Rasmussen poll found that 37% of eligible voters support a single-payer system.
Why Single Payer Is Still a Threat
Even though the single-payer movement has taken a beating recently, Dr Geddes doesn't think it's going to go away. He already sees many aspects of it in Medicare and Medicaid, which depend on central planning.
Dr Geddes says that just like a single-payer system, Medicare imposes arbitrary rules created through central planning. For example, Medicare dictates that certain patients have to be in the hospital for a certain number of days before they can be referred to a rehab hospital. Often, he says, patients can be transferred earlier, but they are forced to stay in a high-cost hospital bed. "The rules actually force doctors to waste resources," he says. "That's how a single-payer system operates."
Furthermore, Dr Geddes thinks the ACA will be just a temporary stop on the way to a single-payer system. Despite cost controls in the ACA, insurance premiums are rising significantly. He believes that health insurance will eventually become unaffordable, and the US public will rise up and call for abolishing private insurance and establishing a single-payer system.
That would be the wrong way to go, Dr Geddes says. "Our private healthcare system is working," he says "We have the finest healthcare system in the world, and it continues to get better."
Even as much of the rest of the world has embraced single-payer and other forms of government-controlled healthcare, such as price controls, they are completely dependent on medical advances created by the US system, he says. Advances in pharmaceuticals, medical equipment, and many surgical techniques come from the United States, where a free market encourages entrepreneurs, Dr Geddes says.
"The incentive is potential windfall profits," he says. "But if you take it away, the whole process of innovation will cease. No other country could take up the slack." Dr Geddes is a regent of the University of Colorado, whose state-of-the-art Anschutz Medical Campus hosts biotech firms financed by venture capital firms and others.
Even within the United States, he says, Medicare and Medicaid depend on the cost shift from private payers. "The only way physicians can afford to participate in Medicare is that they get higher payment from commercial insurers," Dr Geddes says. "Single-payer advocates talk about 'Medicare for all,' but if Medicare were standing alone, it would fall flat."
- Laugesen MJ, Glied SA. Higher fees paid to US physicians drive higher spending for physician services compared to other countries. Health Aff (Millwood). 2011;30:1647-1656. http://content.healthaffairs.org/content/30/9/1647 Accessed August 20, 2015.
- Barua B, Fathers F. Waiting your turn: wait times for health care in Canada, 2014 report. Fraser Institute. November 26, 2014. https://www.fraserinstitute.org/sites/default/files/waiting-your-turn-2014.pdf Accessed August 20, 2015.
- CTV News. Ont. teen facing unnecessary chemo due to bed shortage may soon get transplant. August 7, 2015. http://www.ctvnews.ca/health/ont-teen-facing-unnecessary-chemo-due-to-bed-shortage-may-soon-get-transplant-1.2507061 Accessed August 20, 2015.
- Goswami NP. State gets set to embark on health system overhaul. Rutland Herald. May 22, 2015. http://rutlandherald.com/article/20150522/NEWS03/705229878 Accessed August 20, 2015.
- Newport F. Majority say not gov't duty to provide healthcare for all. Gallup. November 20, 2014. http://www.gallup.com/poll/179501/majority-say-not-gov-duty-provide-healthcare.aspx Accessed August 20, 2015.
- Rasmussen Reports. 37% favor single-payer health care system. April 28, 2014. http://www.rasmussenreports.com/public_content/archive/health_care_update_archive/april_2014/37_favor_single_payer_health_care_system Accessed August 20, 2015.
End of Medical Malpractice Litigation?
Here is an article written by Jeffrey Segal, MD in MedScape. Food for thought.
A Sensible Alternative to Our Broken System?
As every physician knows, our tort system is broken. Various solutions have been suggested over the years, only to fade away. But now, a promising new system for patient compensation in cases of medical error is being proposed in two states: Georgia and Florida. It makes sense for doctors and patients alike, and for our healthcare system as a whole. The bills would, if passed, transform the current medical tort system into an administrative system for redress. Georgia's—the Patient Compensation Act in Georgia, SB 86—opens with the following game-changing text:
"Effective January 1, 2016, the cause of action under Georgia law for medical malpractice against a provider as defined in Code Section 51-13-2 is hereby repealed in its entirety."
A patient who is injured would seek a potential remedy via the Patient Compensation Act, which calls for the establishment of a "Patients' Compensation System."
That patient, via a patient advocate, would appeal to the system to investigate his or her injury. The full record would be reviewed by a rotating collection of medical experts in the relevant field. If this panel agreed that the injury was avoidable, the case would be referred to a compensation committee to make payment.
To qualify for compensation, the panel would, in the Georgia law's verbiage, use the following criteria:
"Medical injury" means a personal injury or wrongful death due to medical treatment, including a missed diagnosis, where all of the following criteria exist:
- The provider performed a medical treatment on the applicant;
- The applicant suffered a medical injury with damages;
- The medical treatment was the proximate cause of the damages; and
- Based on the facts at the time of medical treatment, one or more of the following:
- An accepted method of medical services was not used for treatment;
- An accepted method of medical services was used for treatment, but executed in a substandard fashion.
The patient would not need a lawyer to propel his or her case forward; however, if desired, a lawyer could help the patient ensure that due process was followed. The total pool of funds available for making payments would be less than the aggregate amount of funds doctors paid in professional liability premiums before enactment of the law. In other words, the system would not pay out more in the future than is currently being paid in by physicians. This term would keep costs stable for doctors—by statute—regardless of the number of claims.
The Patients' Compensation System would be a state-based entity and, similar to other state based entities—such as the Florida or Virginia Birth-Related Neurological Injury Compensation programs—payments would not be reportable to the National Practitioner Data Bank (NPDB).
Physicians would not need to purchase medical malpractice insurance, because they could not be sued. Instead, they would pay an annual contribution to administer the program. A family practitioner, for example, would pay $3900 per year; an orthopedic surgeon, $15,600 per year; and a spine surgeon, $17,500 per year. The specialists with the highest contribution rate, pediatric neurosurgeons, would pay $25,300 per year. These rates would be significantly below the current market rate for professional liability premiums—which typically cover only $1 million of liability.
How Physicians Would Benefit
In the Patients' Compensation System, there is no claim to defend. A doctor need only provide the patient's medical record. He or she may ignore any other procedural nuance, if desired. Alternatively, he or she may provide an explanation of care that was rendered.
And if the doctor wants to advocate for the patient, he or she may sit with the patient. If a doctor, for example, misses a critical diagnosis that could have easily be made, and that error cost the patient an extra month in the intensive care unit, the doctor could apologize to the patient and work with him or her in a nonadversarial setting to help the patient achieve reasonable compensation.
Furthermore, there would be no depositions, no cross-examinations, and no shutting down of a practice for 3 weeks to sit in a courtroom. Unlike the current system, there would be no reason to deny and defend.
In the Patients' Compensation System, the doctor incurs no personal financial liability for malpractice. In the current system, professional liability policies cover a limit for damages, usually $1 million. If a judgment exceeds this limit, the doctor is personally liable. This creates pressure on the doctor (and his or her insurer) to settle cases that might be defensible. Unlike in the current system, the doctor is fully "indemnified" for a patient's injury.
In the Patients' Compensation System, settlements and judgments reflecting payments to patients are not reportable to the NPDB. Because—unlike in the current system—payment would be made by the state-based system, such payment would not trigger reporting to the NPDB. As the statutory language states, "'Application' means a request for investigation by the Patients' Compensation System of an alleged occurrence of a medical injury and does not constitute a written demand for payment under any applicable state or federal law" (which might otherwise trigger reporting to the NPDB).
How Patients Would Benefit
In the Patients' Compensation System, all complaints would be reviewed. Currently, low-value claims are generally ignored by plaintiffs' attorneys because the cost of prosecuting such claims exceeds the estimated recovery. In contrast, because low-value claims would be heard under the Patients' Compensation System, more claims would be paid; in other words, more patients would have access to justice.
Payment would be made in months rather than years, as is common now. And the amount paid would be rational, reasonable, and predictable. Physicians would be able to speak openly and plainly about medical errors—enabling broad patient safety initiatives to be implemented.
The bill would allow a three-doctor panel to report any practitioner to the state licensing board who is an imminent danger to the public. A physician who poses such a risk would come to the attention of the board much sooner than under the status quo. Transparency is the starting point for fixing systemic safety problems related to those few physicians who are truly a danger to patients. A system cannot change what it cannot identify or measure.
How the Healthcare System Would Benefit
In the Patients' Compensation System, physicians would have no incentive to practice medicine defensively. Currently, if a doctor fails to order a particular test or imaging study and the patient has a bad outcome, that doctor is at risk for defending against a lawsuit that will last years and potentially bankrupt his or her life savings. Under this paradigm, defensive medicine is rational. As one emergency physician explained, "I will scan patients till they glow if it means avoiding even a day in court."
In the proposed system, doctors would be free to exercise their judgment. For example, if a person experiences a minor concussion, that individual will generally head to an emergency department. A minor concussion might be associated with brief loss of consciousness, nausea, headache, and other symptoms. On arrival in the emergency department, such a patient would ordinarily be neurologically intact. Best practices would include ordering an imaging study only for patients who either have or would be likely to develop an intracranial abnormality.
However, defensive medicine is often at odds with best practices—encouraging, in this hypothetical case, the ordering of an expensive scan and needlessly exposing the patient to radiation, whether or not the patient is deemed to be at risk.
In other words, resources could be saved without causing harm to patients. And patients who are unlikely to develop intracranial pathology would be spared radiation from an unnecessary imaging study. The Patients' Compensation System would create an environment in which defensive medicine would not be needed. If this goal were achieved, the healthcare system would save a fortune.
Challenges to Passing the Bills
Those who benefit from the status quo will fight tooth and nail against change. This includes the trial bar, even though they will have a potential role to play in ensuring that patients' rights are preserved. Plaintiffs' lawyers will argue, for example, that state constitutions guarantee patients trial by jury, and the Patients' Compensation System removes that right.
Of course, old habits die hard. But trial lawyers would not have to risk their money going long on cases that might deliver zero payout. Plaintiffs' lawyers could assist patients without incurring any risk whatsoever, because they would be paid per transaction. Real estate attorneys, for example, have done quite well with such a model. Whether the Patients' Compensation System is constitutional is beyond the scope of this article, but experts who have reviewed the proposed law firmly believe it passes constitutional muster.
What do patients say about a payment system as an alternative to litigation? A Georgia statewide survey by McLaughlin & Associates in August 2013 noted that 63% of participants support "reforming the current medical malpractice system" and 61% favor replacing the current medical malpractice system with a Patients' Compensation System. There is an appetite on the part of the public to scrap what we currently have and try something new.
Citation: Jeffrey Segal. Finally: An End to Malpractice Litigation? Medscape. Mar 05, 2015.
Drug Prescribing Errors: Summary
Poor penmanship was once the bane of prescribing, and the cause of many prescribing errors. Even as electronic prescribing (eRx) has markedly reduced some types of errors, others have cropped up to take their place, and the benefits of eRx are at risk of being overshadowed by unintended consequences.
Recent reports of prescribing errors vary widely, from 5% to 81% of prescriptions.[3,4] A significant proportion of errors are believed to be caused not by system design features or software glitches, but by human factors, such as fatigue, selecting the wrong option, or entering the wrong patient information into an often cumbersome system. And although most prescribing errors are detected and resolved by pharmacists in both the inpatient and community settings,[5-7] some still slip through the entire medication use chain, making it all the way to the patient.
The five main categories of traditional prescribing errors are wrong patient; wrong drug; wrong dose, strength, or frequency; wrong drug formulation; and wrong quantity. In a recent study, the four most common errors observed were wrong drug quantity (40%), wrong duration of therapy (21%), wrong dosing directions (19%), and wrong dosage formulation (11%).
The following serious prescribing errors are consistent with these traditional categories, although with various twists introduced by eRx. These errors, collated from the literature, patient safety experts, and the Institution for Safe Medication Practices (ISMP), are not ranked in any way, but simply represent a sample of potentially serious errors in contemporary drug prescribing.
Prescribing the Wrong Drug
At an outpatient clinic, a clinician used an eRx system to order an antibiotic for a child whose throat culture was positive for group A streptococci. She intended to prescribe penicillin, but accidentally selected penicillamine (a chelating agent used to treat Wilson disease) on the drop-down drug list. The prescription was dispensed by a community pharmacist, and the child received penicillamine 250 mg by mouth twice a day for 2 days. His father noticed that his son appeared pale and sleepy, and his strep throat did not seem to be improving. He showed the medication bottle to the pharmacist, and the error was discovered. The child was treated at the local emergency department.
Some eRx systems autopopulate or present a drop-down menu after the first few letters of the desired drug are typed into a search field, at which point a prescriber might inadvertently select the wrong medication. It is believed that this was one cause of recent prescription and dispensing errors reported to the US Food and Drug Administration involving Brintellix® (vortioxetine, a serotonergic agonist/antagonist) and Brilinta® (ticagrelor, a platelet inhibitor).
The prescriber knows what drug he or she wishes to prescribe. The error comes in trying to convey this to another healthcare provider, such as a pharmacist or nurse. This can occur when the prescriber's handwriting is less than crystal-clear, as in the photo above. The pharmacist or nurse misreads the prescriber's handwritten prescription, the mind substituting a similar-looking drug, and a wrong drug medication error is born. In the illustration here, the intended drug PreNexa® was misread as Ranexa®, and the latter was dispensed. Illegibility continues to be a significant source of prescribing error in ambulatory settings.
The 21st-century equivalent of poor penmanship is the long list of look-alike, sound-alike (LASA) drugs on a drop-down screen. The prescriber opens a menu of drugs (many of which have similar or identical stems) and inadvertently selects the wrong drug, frequency, or quantity; this order is then transmitted to the pharmacy. If the system does not require the prescriber to enter an indication for the drug, it is difficult for a pharmacist to know that the wrong drug has been ordered.
ISMP recommends "Tall Man lettering" (mixed case or capitalized letters within drug names to highlight primary dissimilarities with look-alike drug names, such as hydrOXYzine and hydrALAZINE) as a means of reducing the risk for drug selection errors. It also helps to include both the brand name and generic name on prescriptions. Most LASA drugs also have different indications, so indication prompts can be useful to intercept drug selection errors. Where possible, practices should consider limiting the number of drugs that show up on drug selection menus to those that are most commonly prescribed in that practice.
Drug modifiers for different drug formulations are common,such as the once-daily formulation Wellbutrin XL® (bupropion extended-release) and Wellbutrin SR® (bupropion sustained-release), which is indicated for twice-daily dosing. Wellbutrin mix-ups are especially likely because both the SR and XL formulations are available in 150-mg tablet strengths, and it's not unusual for the SR formulation to be prescribed once daily.
The anticonvulsant agent Depakote® is another drug with multiple modifiers. It is available as delayed-release capsules (Depakote Sprinkles), delayed-release tablets (Depakote), and extended-release tablets (Depakote ER).
A clinician intended to prescribe 1500 mg of Depakote ER to a patient with a seizure disorder. However, several formulations of Depakote (delayed release, extended release, tablets, and capsules) were listed on the drop-down menu, and the clinician selected delayed-release instead of extended-release. Nine hours later, the patient received the full 1500-mg dose of Depakote at once, because the full dose of delayed-release Depakote enters the circulation more rapidly than the extended-release formulation. The patient developed significant hypotension and sedation but eventually recovered.
Many prescribers and pharmacists have noticed the high potential for confusion among the various formulations of drugs, and errors of formulation selection are common.[13,14] The modifiers for short-acting, intermediate-acting, and long-acting formulations are not standardized in the industry. ER (extended-release) may mean a 24-hour formulation for one drug and a 12-hour formulation for another drug. The United States Pharmacopeia defines delayed-release tablets as enteric-coated, intended to delay the release of the medication until the tablet has passed through the stomach to prevent the drug from being inactivated by gastric secretions or to prevent gastric mucosa irritation. Extended-release tablets are formulated to make the drug available over an extended period after ingestion. The delayed-release formulation of Depakote is enteric-coated, whereas Depakote ER is not enteric-coated. They are not bioequivalent or interchangeable. Another agent that is often involved in serious formulation prescribing errors is insulin.
As more drug product lines expand to offer different formulations, this type of error could become more common. The best way to prevent such errors is to become familiar with the different modifiers on prescribed medications. Be explicit in the dosing directions for the frequency that you want the medication taken, and tell the patient exactly how it should be taken. Most often, if a mistake is made, the pharmacist will contact the prescriber because the frequency is not consistent with the formulation.
A 33-year-old woman with refractory epilepsy was admitted to the hospital with increasing frequency of seizures. Her seizures were controlled with fosphenytoin, and she was discharged 2 days later with a prescription for phenytoin, 500 mg once daily. However, the clinician inadvertently failed to change the default frequency (three times daily) to the desired frequency of once daily, and ignored an overdose alert triggered by the excessive daily dose. In this case, the pharmacist also missed the high-dose alert, and dispensed the phenytoin with instructions to take three times daily. The patient took the phenytoin as instructed for a few days, but when she began having trouble walking, the error was discovered. The patient experienced transient phenytoin toxicity.[
presented during the order entry process also can interfere with the prescriber's concentration, increasing the likelihood of error.
Most alerts (even those warning of high-severity drug interactions) are rejected or ignored by clinicians.[18,19] In one recent study, 93% of drug/drug interaction and drug-allergy alerts were overridden. Too many alerts with low credibility can induce prescribers to override important alerts along with false-positives, a phenomenon known as "alert fatigue."
Perhaps nowhere is the human/computer interaction as important as in the prescriber's response to alerts. This case demonstrates that prescribers can become desensitized to alerts. To minimize this, alerts in the eRx system must be both sensitive and specific, and only alerts that warn of potential errors should be presented, not irrelevant or redundant messages. The threat of missing a rare event must be balanced with the dangers of burdening clinicians with unnecessary and interruptive electronic alerts. The credibility of prescribing alerts can be improved by reducing alerts that contradict broadly accepted clinical practices. It is also recommended that alerts be tiered according to severity, and that they be presented to prescribers at an appropriate place in the workflow to improve prescribing efficiency.[19,22]
And what, if anything, would prescribers like to see more alerts for? Lab values, and a list of drugs prescribed for the patient by other providers.
Failure to Adjust
A 71-year-old woman receiving palliative chemotherapy for lung cancer developed methicillin-resistant Staphylococcus aureus bacteremia. Vancomycin 1.25 g was given, and she was transferred to a referral hospital. Her serum creatinine level at the community hospital was 0.4 mg/dL, and at the referral hospital, it had doubled to 0.8 mg/dL (although this was still within the normal range). Vancomycin was continued. By the next day, she was in acute renal failure with an elevated creatinine level. A vancomycin trough level was obtained, and reported as 64 mg/L. Her renal failure worsened; she became anuric and required urgent dialysis.
Vancomycin is renally eliminated and has a narrow therapeutic index with a high potential for nephrotoxicity. The admitting clinician neither recognized the doubling of this patient's serum creatinine level nor ordered a vancomycin trough level.
Chronic kidney disease (CKD) is an increasing concern in elderly persons. Senile pharmacokinetic changes in the kidney include dysautonomia; glomerular filtration rate reduction; tubular back-filtration; sodium, calcium, and magnesium loss; potassium retention; altered dilution-concentration capability; and tubular frailty. Furthermore, elderly patients are frequently on multiple medications to manage their many comorbid conditions. The early stages of CKD are often unrecognized, placing the elderly person at high risk for serious, yet largely preventable, drug-related safety events.[26,27] Indeed, inappropriate prescribing of renally cleared drugs is common in adults.[28,29] A recent study identified perindopril, fenofibrate, glibenclamide, gliptins, metformin, olmesartan, bisphosphonates, and strontium as drugs frequently prescribed to elderly adults without evaluation of renal function.
It is essential to consider renal function when prescribing renally cleared drugs in this population and make appropriate dosage adjustments. Either the Cockcroft-Gault equation or the Modification of Diet in Renal Disease (MDRD) study equation can be used for routine estimation of glomerular filtration rate (GFR), although the MDRD is considered superior in patients with low GFR (< 60 mL/min/1.73 m2).[31,32] The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, issued by the American Geriatric Society (AGS), is also an important resource when prescribing for older adults. AGS released updated criteria in 2015.
Phoning It In
A 56-year-old man was hospitalized for replacement of a percutaneous endoscopic gastrostomy tube. He was on warfarin owing to a history of intracardiac mural thrombus, but his international normalized ratio (INR) was low. His medical team decided to increase his warfarin from 5 mg/day to 10 mg/day for 3 days to raise his INR. Later that day, on review of his case, it was decided to stop warfarin altogether until an echocardiogram could be obtained to evaluate whether he still had intracardiac thrombus. The resident started to enter the order into his smartphone but was interrupted by a personal text. After answering the text, he forgot to complete the order to discontinue warfarin. As a result, the patient continued to receive 10 mg daily. On the fourth day, he experienced shortness of breath, tachycardia, and hypotension. An echocardiogram showed hemipericardium and tamponade, requiring emergency open heart surgery.
As of 2014, smartphones were being used by one third of physicians to prescribe. The use of such mobile devices as smartphones and tablets can increase the convenience of prescribing, but not without a cost to patient safety. Having clinical information and decision support at one's fingertips could improve the timeliness of care, but mobile technologies also pose such risks as transmission of infection; interference from electromagnetic radiation; breach of confidentiality; multitasking, and as shown in the case, interruption and distraction.
Institutions are challenged to develop policies and technologies for mitigating the risks associated with mobile prescribing, to capture their benefits while reducing their harm. However, the safe use of mobile devices falls heavily on the shoulders of individual prescribers, to ensure that personal communications or interruptions do not pose risks to patient safety.
Errors In, Errors Out
A 17-month-old toddler was brought in to the emergency department for evaluation of an eye infection. The nurse weighed the toddler and recorded the weight in the chart. However, the nurse entered "25 kg" instead of "25 lb" (11.3 kg). The physician prescribed clindamycin 225 mg orally three times daily, calculated using the weight of 25 kg, and the first dose was given before discharge. The child's mother noticed the incorrect weight on the discharge paperwork, and the dose was corrected. The child suffered only diarrhea from the incident.
Wrong, outdated, or missing information can result in myriad prescribing errors. Patient information that is critical to prescribing includes allergies, medical history, current medication list, body weight, and laboratory data. Body weights should always be recorded using the metric system, because that is how drugs are dosed. When such information is missing or out of date, errors in prescribing may follow. In one incident, staff failed to record in the chart that a woman with chronic asthma was pregnant, and she was given bronchodilators, corticosteroids, and intravenous levofloxacin (a pregnancy category C drug).
To save time, prescribers often will use abbreviations, especially in handwritten prescriptions. Prescribers may abbreviate a long drug name, use an often misunderstood symbol, or use abbreviations for dosing or administration instructions. This category of error also includes misuse of decimals (leading and trailing zeros) and other symbols. These shortcuts might save the prescriber a few seconds of writing, but can spell confusion for other healthcare professionals downstream and potential harm for the patient. Abramson and colleagues found a very high rate of abbreviation errors in their study of outpatient prescribing errors.
In the cases illustrated in this slide, the first prescriber (top) intended for the order to read "Dilaudid 0.6 mg Q 10′ PRN (every 10 minutes as needed)," but it was read as "Dilaudid 0.6 mg QID PRN (4 times daily as needed)." The second prescriber (middle) intended to prescribe potassium chloride QD (daily), but the prescription was misread as QID (4 times daily). The use of "Pot" as an abbreviation for potassium is also error-prone and is not recommended. The order for vincristine (bottom) was intended to be a dose of 0.4 mg, but the decimal point was misplaced and barely visible. It was read as "4 mg vincristine." This type of error can be prevented by using a leading zero for doses less than one.
eRx is not immune to confusion from error-prone abbreviations. In some electronic systems, decimal points are difficult to visualize, making wrong dose selections more likely.
Drug name abbreviations are often confused (eg, MgSO4 for morphine). The simplest way to avoid misinterpretation of drug name abbreviations is to fully spell out drug names and directions. If abbreviations must be used, use only standard abbreviations approved by the acute care institution and avoid abbreviations completely for outpatient prescriptions. ISMP provides a list of error-prone abbreviations, symbols, and dose designations, and the Joint Commission has a "Do Not Use" list. These include the commonly used abbreviations µg, OU, and D/C, which should instead be written as "mcg," "both eyes," and "discharge" (or "discontinue"), respectively.
Wrong patient. An emergency medicine physician inadvertently switched medication orders on two patients. One was in the emergency department for intravenous hydration, and the other had been in a motor vehicle accident and was going to be intubated and transferred to a trauma center. Because of the switch, the hydration patient received midazolam and vecuronium, went into respiratory arrest, and died.
Wrong patient errors are being reported more frequently with eRx. In the pre-electronic era, unless it was a telephone order, the prescriber had to be physically present on the unit, because that is where the chart was located. With computerized charting, it is possible to have several patient files open at the same time and inadvertently click on the wrong chart to enter the order. Alternatively, the prescriber is on a different unit, and enters a remote order on the wrong patient because of similarity in patient names.
Some wrong patient errors can be prevented by limiting the number of charts or files that can be open at one time. Many electronic health records (although not all) have this feature built in. An exception is often made for the emergency department.
Wrong dose or frequency selection. Like picking the wrong drug, clicking on the wrong dose or frequency from the numerous choices typically displayed on drop-down menus can easily occur. Sometimes, prescribers have entered the wrong frequency, or left the default frequency and used a comment field to communicate the correct information through free text. These instructions may be ambiguous or confusing and, furthermore, often appear several screens after the main screen and are easily overlooked by the pharmacist. The drug is then dispensed with the wrong or the default frequency.
Errors in dose calculation. A potentially serious prescribing error is miscalculating a dose, especially with weight-based dosing. Historically, "decimal point errors" made during calculations have been responsible for serious prescribing overdoses in neonates and children.
Failure to Deprescribe
An 86-year-old woman is seeing a new healthcare provider because her previous provider has retired, and she is experiencing pain, insomnia, and diarrhea. She is being treated for mild heart failure secondary to valve disease, hypertension, hyperlipidemia, glaucoma, depression, chronic kidney disease, and diabetes. She reports an increase in dizziness as of late; she is having trouble getting into and out of the bathtub. She knows that she takes a handful of pills daily but is not sure what they are for. Her healthcare provider looks at her current medication list, and although he realizes that this list represents polypharmacy, he is reluctant to change anything at this time because he is not familiar with her history and why she is taking these medications. Instead, he refills several of her medications. Two days later, the woman gets up during the night because she can't sleep, intending to make some tea. She is dizzy, and falls and breaks her hip and her humerus, requiring surgery.
Some experts distinguish between prescribing errors and prescribing faults. Prescribing errors are those made in the act of writing or entering a prescription, whereas prescribing faults include irrational prescribing, inappropriate prescribing, underprescribing, overprescribing, and ineffective prescribing, as a result of erroneous medical judgement, treatment decisions, or treatment monitoring.
Deprescribing is the act of tapering, reducing, or stopping a medication. The failure to deprescribe ("prescribing inertia") is a prescribing fault that is especially dangerous in the elderly population, who might already be taking a handful of pills every day. When a new drug is prescribed, the risk for drug/drug interactions and adverse events rises. Polypharmacy in older adults is associated with, at the very least, falls, cognitive impairment, and increased mortality.[43-45]
Barriers to deprescribing include ambivalence about stopping medications, reticence to stop medications prescribed by others, limited knowledge about best practice for stopping medications, and concern about potential withdrawal. However, deprescribing has a major benefit for eRx because it can reduce the number of pesky alerts about potential drug interactions.
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- Odukoya OK, Stone JA, Chui MA. How do community pharmacies recover from e-prescription errors? Res Social Adm Pharm. 2014;10:837-852.
- Gaunt MJ. Drug name confusions. Pharmacy Times. November 12, 2012. http://www.pharmacytimes.com/publications/issue/2012/november2012/drug-name-confusions Accessed September 10, 2015.
- Lowes R. FDA warns of Brintellix, Brilinta name confusion. Medscape Medical News. July 30, 2015. http://www.medscape.com/viewarticle/848866 Accessed September 8, 2015.
- Institute for Safe Medication Practices. ISMP's list of confused drug names. https://www.ismp.org/tools/confuseddrugnames.pdf Accessed September 6, 2015.
- Galanter WL, Bryson ML, Falck S, et al. Indication alerts intercept drug name confusion errors during computerized entry of medication orders. PloS One. 2014;9:e101977.
- Institute for Safe Medication Practices. Depakote ER—easy to confuse with Depakote delayed release. ISMP Medication Safety Alert. 2001;6. https://www.ismp.org/newsletters/acutecare/articles/20010207-1.asp Accessed September 6, 2015.
- Fava W, Holquist C. Delayed release vs. extended release Rxs. DrugTopics. July 23, 2007. http://drugtopics.modernmedicine.com/drug-topics/news/clinical/pharmacy/fda-safety-page-delayed-release-vs-extended-release-rxs?page=full Accessed September 6, 2015.
- Drug name suffix confusion is a common source of error. Pennsylvania Patient Safety Advisory. 2004;1:17-18. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2004/dec1(4)/Pages/17.aspx# Accessed September 27, 2015.
- Lesar TS. Prescribing errors involving medication dosage forms. J Gen Intern Med. 2002;17:579-587.
- Baysari M. Finding fault with default alert. AHRQ Patient Safety Network. WebM&M. October 2013. http://webmm.ahrq.gov/case.aspx?caseID=310 Accessed September 7, 2015.
- Russ AL, Zillich AJ, McManus MS, Doebbeling BN, Saleem JJ. Prescribers' interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the human-computer interaction. Int J Med Inform. 2012;81:232-243.
- van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13:138-147.
- Coleman JJ, Hodson J, Thomas SK, Brooks HL, Ferner RE. Temporal and other factors that influence the time doctors take to prescribe using an electronic prescribing system. J Am Med Inform Assoc. 2015;22:206-212.
- Bryant AD, Fletcher GS, Payne TH. Drug interaction alert override rates in the meaningful use era: no evidence of progress. Appl Clin Inform. 2014;5:802-813.
- Carspecken CW, Sharek PJ, Longhurst C, Pageler NM. A clinical case of electronic health record drug alert fatigue: consequences for patient outcome. Pediatrics. 2013;131:e1970-e1973.
- Isaac T, Weissman JS, Davis RB, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169:305-311.
- Wong-Beringer A. Failure to reevaluate. AHRQ Patient Safety Network. WebM&M. December 2010. http://webmm.ahrq.gov/case.aspx?caseID=232 Accessed September 6, 2015.
- Stevens LA, Viswanathan G, Weiner DE. Chronic kidney disease and end-stage renal disease in the elderly population: current prevalence, future projections, and clinical significance. Adv Chronic Kidney Dis. 2010;17:293-301.
- Musso CG, Belloso WH, Scibona P, Bellizzi V, Macías Núñez JF. Impact of renal aging on drug therapy. Postgrad Med. 2015;127:623-629.
- Hug BL, Witkowski DJ, Sox CM, et al. Occurrence of adverse, often preventable, events in community hospitals involving nephrotoxic drugs or those excreted by the kidney. Kidney Int. 2009;76:1192-1198.
- Fink JC, Joy MS, St Peter WL, Wahba IM; ASN Chronic Kidney Disease Advisory Group. Finding a common language for patient safety in CKD. Clin J Am Soc Nephrol. 2012;7:689-695.
- Yap C, Dunham D, Thompson J, Baker D. Medication dosing errors for patients with renal insufficiency in ambulatory care. Jt Comm J Qual Patient Saf. 2005;31:514-521.
- Khanal A, Peterson GM, Castelino RL, Jose MD. Potentially inappropriate prescribing of renally cleared drugs in elderly patients in community and aged care settings. Drugs Aging. 2015;32:391-400.
- Lassiter J, Bennett WM, Olyaei AJ. Drug dosing in elderly patients with chronic kidney disease. Clin Geriatr Med. 2013;29:657-705.
- Poggio ED, Wang X, Greene T, Van Lente F, Hall PM. Performance of the modification of diet in renal disease and Cockcroft-Gault equations in the estimation of GFR in health and in chronic kidney disease. J Am Soc Nephrol. 2005;16:459-466.
- Erler A, Beyer M, Petersen JJ, et al. How to improve drug dosing for patients with renal impairment in primary care—a cluster-randomized controlled trial. BMC Fam Pract. 2012;13:91.
- American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:616-631. http://www.medscape.com/viewarticle/762283 Accessed September 9, 2015.
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- Alvarez A. What tasks are physicians performing on their smartphones? Kantar Media. October 22, 2014. http://www.kantarmedia-healthcare.com/what-tasks-are-physicians-performing-on-their-smartphones Accessed September 8, 2015.
- Bokser SJ. A weighty mistake. Morbidity and Mortality Rounds on the Web. March, 2013. http://webmm.ahrq.gov/case.aspx?caseID=293. Accessed September 7, 2015.
- Abramson EL, Bates DW, Jenter C, et al. Ambulatory prescribing errors among community-based providers in two states. J Am Med Inform Assoc. 2012;19:644-648.
- Institute for Safe Medication Practices. Oops sorry, wrong patient. ISMP Medication Safety Alert. 2011;16. https://www.ismp.org/newsletters/acutecare/articles/20110310.asp Accessed September 7, 2015.
- Lesar TS. Tenfold medication dose prescribing errors. Ann Pharmacother. 2002;36:1833-1839.
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- Farrell B, Tsang C, Raman-Wilms L, Irving H, Conklin J, Pottie K. What are priorities for deprescribing for elderly patients? Capturing the voice of practitioners: a modified delphi process. PLoS One. 2015;10:e0122246.
- Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5:345-351.
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Published on Medscape: October 22,2015 Authors: Graham, LR, Scudder L, Stokowski L
Narcan Nasal Spray to Counteract Narcotic Overdose
A common cause of death is narcotic overdose, accidental and intentional. The approval of nasal narcan is a major breaththrough in the timely treatment of this dangerous situation.
An intranasal form of naloxone hydrochloride (Narcan, Adapt Pharma, Inc), a drug that stops or reverses opioid overdose, has been approved by the US Food and Drug Administration (FDA) under a fast-track approval process.
Naloxone hydrochloride has long been given by intramuscular injection to stop or reverse the effects of opioid overdose, in particular respiratory depression. It usually works within 2 minutes but must be given quickly to prevent death.
The nasal form will be easier for first responders and others to deliver, and will eliminate the threat of contaminated needle sticks. Until now, unapproved naloxone kits have combined the injectable form of naloxone with an atomizer to administer the drug nasally.
No assembly is required for the approved nasal product, and anyone can administer it, even those without medical training. The product can be given to adults and children. It is sprayed into one nostril while the patient lies on his or her back, and can be repeated if needed. The FDA cautions that the person administering the drug should still seek immediate medical attention for the patient.
Drug overdose deaths have risen steadily for the past decade and now surpass motor vehicle crashes as the leading cause of injury death in the United States. The increase is due in large part to prescription drug overdoses, as well as a rise in heroin use.
"Combating the opioid abuse epidemic is a top priority for the FDA," Stephen Ostroff, MD, acting FDA commissioner, said in an FDA news release. "We cannot stand by while Americans are dying. While naloxone will not solve the underlying problems of the opioid epidemic, we are speeding to review new formulations that will ultimately save lives that might otherwise be lost to drug addiction and overdose."
The approval follows an expedited review of data from clinical trials in which nasal administration achieved the same or higher levels of naloxone as those obtained with intramuscular injection, and in about the same amount of time.
The FDA's priority review program facilitates approval of drugs that are expected to significantly improve the safety or effectiveness of the prevention, treatment, or diagnosis of a serious medical condition. The FDA approved the nasal spray in less than 4 months.
Narcan Nasal Spray to Counter Opiate Overdose Approved by FDA
"We heard the public call for this new route of administration, and we are happy to have been able to move so quickly on a product we are confident will deliver consistently adequate levels of the medication — a critical attribute for this emergency life-saving drug," Janet Woodcock, MD, director of the FDA's Center for Drug Evaluation and Research, said in the FDA news release.
The National Institute on Drug Abuse (NIDA) designed and conducted clinical trials to determine that the intranasal formulation worked as quickly and effectively as the injectable form. NIDA then worked with its partners in the private sector to obtain approval from the FDA.
"This easy-to-use intranasal formulation will no doubt save many lives," Nora Volkow, MD, director, National Institute on Drug Abuse at the National Institutes of Health, explained in the news release. "While prevention is the ultimate goal, the drug's successful development illustrates how public/private scientific partnerships can play an important role in responding to a national crisis right now."
Health and Human Services Secretary Sylvia M. Burwell proposed a targeted strategy for addressing the opioid epidemic that includes increasing access to and use of naloxone in March. In July the FDA sponsored a public workshop at which addiction and advocacy groups demanded expanded availability of the lifesaving drug.
Naloxone nasal spray can cause severe opioid withdrawal in patients who are opioid dependent.
Fentanyl Narcotic as a Street Drug--Fatalities
The Centers for Disease Control and Prevention (CDC) has issued a warning regarding increases in fentanyl drug confiscations and a potential increased risk for fentanyl-related overdose fatalities.
According to the CDC, reports from the National Forensic Laboratory Information System, a program of the Drug Enforcement Administration's (DEA's) Office of Diversion Control, indicate there has been a significant increase in the confiscation of illicit fentanyl by authorities from 2012 to 2014, raising concerns that these drug seizures may be a proxy for increased overdose risk.
The reports show there were 618 such drug seizures in 2012, 945 in 2013, and 4585 in 2014. More than 80% of drug seizures in 2014 (3790) were concentrated in 10 states. Ohio had by far the highest number (1245), which was almost twice as many as occurred in Massachusetts (630). Pennsylvania was next with 419 seizures. Maryland, New Jersey, Kentucky, Virginia, Florida, New Hampshire, and Indiana were also on the "top 10" list.
The number of states reporting 20 or more fentanyl seizures every 6 months is also increasing, according to the CDC's Health Alert Network advisory. From July to December 2014, 18 states reported 20 or more fentanyl drug seizures. In contrast, six states reported 20 or more illicit fentanyl drug seizures during the same period in 2013.
In addition, recent data suggest that fentanyl-related fatalities have increased in states reporting large increases in fentanyl seizures. Two of the top five seizure states, Ohio and Maryland, reported sharp increases in fentanyl-related deaths in 2014.
The CDC notes that, similar to previous fentanyl overdose outbreaks, most of the more than 700 fentanyl-related overdose deaths reported during this period were attributable to illicitly manufactured fentanyl — not diverted pharmaceutical fentanyl — that was mixed with either heroin or other diluents and sold as a highly potent substance, sometimes under the street name "China White."
However, the true number of fentanyl-related overdose deaths is likely higher because many coroners' offices and state crime laboratories do not test for fentanyl or its analogues unless given a specific reason to do so, the DEA noted.
Nonpharmaceutical fentanyl (NPF) is sold illicitly for its heroinlike effect and is often mixed with heroin and/or cocaine ― sometimes without the user's knowledge ― to increase its euphoric effects. Although NPF-related overdoses can be reversed with naloxone (multiple brands), a higher dose or multiple doses may be required to revive a patient, owing to the high potency of NPF.
In addition to alerting healthcare providers, public health departments, first responders, and others to possible additional fentanyl-related seizures and overdoses, the CDC advisory makes recommendations for improving detection of fentanyl-related overdose outbreaks.
For example, the CDC suggests that public health departments explore methods for more rapidly detecting outbreaks and that they use existing surveillance systems, such as medical examiner data, emergency medical services data, or near-real-time emergency department data.
It also suggests that in situations of dramatically increased opioid overdoses, consideration be given to asking emergency departments to report fatal and nonfatal opioid overdose cases to them within 48 hours and to engaging local poison control centers to help track and treat patients.
The CDC suggests that medical examiners and coroners screen for fentanyl in suspected opioid overdose cases in regions reporting increases in fentanyl seizures, fentanyl-related overdose fatalities, or unusually high spikes in heroin or unspecified drug overdose fatalities.
It also recommends that these experts screen specimens from fatal drug overdose deaths using an enzyme-linked immunosorbent assay (ELISA) with the capacity to detect fentanyl.
The CDC noted that law enforcement personnel can play an important role in identifying and responding to increases in the distribution and use of illicitly manufactured fentanyl.
It also advised that investigating officers consider their potential exposure to fentanyl through skin and/or inhalation of aerosolized drug and to use appropriate safety precautions and personal protective equipment.
The CDC also recommends that law enforcement agencies share data on fentanyl and acetyl-fentanyl drug seizures with local health departments, coroners, and medical examiners.
The End of Medical Malpractice Lawsuits?
Is Legislation to End Malpractice Lawsuits Realistic?
A recent Medscape article contended that controversial legislation now wending its way through the Georgia and Florida legislatures would, if enacted, put an end to malpractice litigation in those states and could serve as a template for other states to follow suit, replacing the current medical tort system with an administrative system for redress. The patient, via a patient advocate, would appeal to the system to investigate an injury. The full record would be reviewed by a rotating panel of relevant medical experts. If the panel agreed that the injury was avoidable, the case would be referred to a compensation committee to make payment.
The patient would not need a lawyer, although he or she could have one to ensure that due process was followed. Physicians would not need malpractice insurance because they could not be sued. Instead, they would pay an annual contribution to administer to the program—rates, the article contended, that would be significantly below the current market rate for professional liability premiums. In response, Hal Dasinger, JD, Vice President of Government Relations at the Napa, California-based Doctors Company, the nation's largest physician-owned medical malpractice insurer, offers the following counterpoint.
An End to Malpractice Lawsuits?
In recent years, physicians, other health care providers, and lawmakers across the United States have been addressed by keynote speakers, pitched to, surveyed, and lobbied by people promoting a proposal that would replace civil litigation for claims of medical professional liability with an administrative process for compensating patients for avoidable injuries.
The proponents claim that their administrative system has several advantages over civil litigation. The most striking of these claims, and the source of much of the initial physician interest in the idea, is the promise that physicians will no longer be sued. Next, the proponents claim that payments to patients will not be reported to the National Practitioner Data Bank (NPDB). Finally, proponents say that far more claims would be paid to patients who have suffered genuine harm, but who aren't able obtain legal representation under the current tort system because their cases are too insignificant to be potentially profitable—yet system costs would not exceed current levels.
That last promise is the key to understanding this proposal, and also its most fundamental flaw. Proponents insist that because the process is nonadversarial, defensive medicine—treatment designed primarily to avoid liability rather than to improve the patient's health—would all but disappear, producing savings on overall healthcare spending.
Even if we accept these proponents' estimate of the cost of defensive medicine, which Gallup reports is 1 in 4 health care dollars, or about $650 billion annually—an estimate that has been widely criticized as excessive—there is no assurance that this cost will decrease.
Under the plan, a panel of experts would review each claim to determine whether an injury was avoidable. Plan administrators would have discretion in reporting providers to their state medical boards. This assignment of causation and culpability is not conceptually different from finding fault. There may be fewer depositions, and certainly fewer opportunities for physicians to defend their actions, but the likelihood is that defensive medicine will continue.
Will the Proposed System Actually Cost More?
Nor is the cost of defensive medicine the only problem with the promise to reduce costs. The proposal promises to compensate far more patients than currently receive settlements or jury awards through the courts, and to do so according to a payment schedule using NPDB data for typical payments for particular types of injuries. More payments at current average-per-claim values can only result in far more money paid out. This inevitable increase in costs is addressed in the versions of the bill introduced so far in a manner unlikely to satisfy anyone trying to calculate costs and benefits: The proposed statutes explicitly prohibit compensation from exceeding current medical professional liability costs.
To repeat: Simple math says the new system will cost more, but the proposed law says it won't.
You don't have to be an actuary to spot the problem with that legislative requirement. As it happens, actuaries consulted about the proposal agree that costs will inevitably rise. The proponents' own study estimated a 13% increase from the bill introduced in Georgia.Others put that figure from 35% to over 100%. Compensation for insignificant injuries would rise an estimated 1730%.
The most recent versions of the bills seeking to install this process rely on physician surcharges to pay for patient compensation, costs of handling the claims, and presumably a fee for the entity providing the administrative support. If any state enacts this proposal, when the actual costs exceed the stated estimates and swamp the available funds, some combination of undesirable effects will follow soon after: Physician surcharges will increase, payments to patients will decrease, or the criteria for compensation will tighten—or perhaps all of these will occur.
In short, the benefits promised will disappear, but the shortcomings of the administrative process will remain. The state will have to subsidize the fund or scrap the program altogether, and taxpayers, physicians, and patients will be left picking up the pieces.
Will You Avoid Being Reported to the NPDB?
The pronouncement that physicians in the system will not be reported to the NPDB is no more credible. No state has adopted this plan, so no definitive opinion is available. However, recent action by the Department of Health and Human Services (HHS) regarding new legislation in Oregon and Massachusetts is instructive.
Both states enacted alternative programs for dealing with medical injury, although neither went as far as the administrative model proposed in Georgia, Florida, and elsewhere. Both states sought rulings from HHS that payments under their alternative models be exempt from reporting to NPDB. Both were instructed that payments are reportable. And before any objection is raised that the situations aren't comparable, take a look at the first paragraph of the HHS decision:
Although the Massachusetts and Oregon medical malpractice reform models are the only two existing models of their type, based in legislation, other states (including Florida and Georgia) are examining similar models for future implementation.
Much of the momentum behind these proposals has been generated by promising physicians that they will never be sued. Unfortunately, this promise will prove as impossible to keep as the others. The right to jury trial for medical injury is a feature of common law; is guaranteed by many state constitutions; and has been clearly enunciated by the state supreme courts in Georgia, Illinois, Missouri, Oregon, and a multitude of other states. Substituting administrative review as an exclusive remedy for medical injury will not stand up to the criteria applied even to proven, effective reforms. The former Georgia attorney general wrote an opinion to that effect, and no credible counter has been offered by the proponents.
Too Good to Be True?
No one will argue that civil litigation is an efficient way to compensate legitimate claimants for their injuries. But the proposed substitute doesn't stand up to legal scrutiny, actuarial analysis, or logical examination. Legislation seeking to establish this administrative substitute has been introduced in a number of states, usually under the guise of tort reform. So far, none of these bills has been successful.
Advocates for patients and for physicians should be wary of any plan promising to both increase payments and decrease costs. If something seems too good to be true, it probably is. In the case of this particular proposal, both patients and providers stand to lose when the plan inevitably fails to keep the promises made by its proponents.
Scherz H, Oliver W. Defensive medicine: a cure worse than the disease. Forbes. August 27, 2013.http://www.forbes.com/sites/realspin/2013/08/27/defensive-medicine-a-cure-worse-than-the-disease Accessed July 20, 2013.
Larcher G. Georgia Senate Bill 141: Patients Compensation System. Aon Risk Solutions. October 22, 2013.
An evaluation of the impact to direct medical malpractice costs in the state of Georgia related to the implementation of a patients compensation system. Aon Risk Solutions.October 10, 2012.
Wakefield MK. Appropriate medical malpractice payment reporting to the National Practitioner Data Bank (NPDB) in light of recent medical malpractice Reforms in Massachusetts and Oregon—decision. Department of Health and Human Services. May 20, 2014. http://www.citizen.org/documents/2211%20Enclosure.pdf Accessed July 20, 2015.
Bowers MJ. The proposed Patient Injury Act would not meet the requirements of Ga. Const. Art. 1, Sec. 1, Par. XI (a). Balch & Bingham LLP. November 28, 2012.http://pdfserver.amlaw.com/dailyreport/Editorial/PDF/Bowers_letter_on_bad_faith.pdf Accessed July 20, 2015.
Medscape Business of Medicine © 2015 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this article: Hal Dasinger. Is Legislation to End Malpractice Lawsuits Realistic? Medscape. Jul 30, 2015.
Bupropion use is on the rise!
Bupropion, otherwise known as Wellbutrin, is commonly prescribed for major depression, and for smoking cessation. It's major adverse side effects are seizures; but there are additional adverse effects too. In high enough doses it also increases sexual desire in men and women, and produces a high that has been compared to that of cocaine. The following report describes the data of increasing use. A future blog entry will discuss the problems associated with bupropion abuse.
The proportion of bupropion prescriptions that were refilled under circumstances that suggest misuse or diversion increased roughly 10-fold in Ontario, Canada, during a 13-year period, according to a study published in the July/August issue of the Annals of Family Medicine.
In the final study year, such questionable prescriptions totaled an estimated 48,000 pills of the drug, which is clinically used to treat depression and to support smoking cessation efforts. People who abuse the drug say it provides a cocaine-like high.
"These findings suggest a troubling phenomenon that bupropion prescriptions are being used recreationally at an increasing rate," write the investigators, led by Leah S. Steele, MD, PhD, from the Institute for Clinical Evaluative Sciences; St. Michael's Hospital; and the University of Toronto in Ontario, Canada.
"Physicians and pharmacists should be aware of the potential for bupropion misuse, particularly in patients prone to substance use disorders or those who display unusual drug-seeking behaviors," they write. "Adding questions about misuse of bupropion to population-based drug use surveys could help determine the extent of the problem."
The serial cross-sectional study included data from Ontarians younger than 65 years and not residing in long-term care facilities who received prescriptions under the province's public drug program from April 1, 2000, to March 31, 2013.
The investigators ascertained the quarterly number of bupropion prescriptions that were potentially inappropriate, defined as early refills dispensed within half of the duration of the preceding prescription, and that were potentially duplicitous, defined as such early refills originating from a different prescriber and different pharmacy. They conducted the same analyses for citalopram and sertraline, which are antidepressants not known to be prone to abuse.
Overall, the authors identified 1,780,802 prescriptions for bupropion, 3,402,462 for citalopram, and 1,775,285 for sertraline.
There was a sharp rise in potentially duplicitous prescriptions for bupropion during the study period, going from less than 0.05% of all prescriptions to 0.47%, with greatest increase seen after 2008. In the final study quarter, this 0.47% rate was significantly higher than that for both citalopram (0.11%) and sertraline (0.12%).
However, the rate of early refills for bupropion fell during the study period, from 4.8% to 3.1%, as did the rate for the other two drugs. In the final quarter, the 3.1% rate of early refills for bupropion was significantly higher than that for citalopram (2.2%), but not that for sertraline (2.9%).
The investigators note that the public drug program from which the study data were derived accounts for less than half of all prescription drug expenditures in Ontario. "Consequently, although we identified a large proportion of anomalous bupropion prescriptions in the province, the total number is necessarily higher," they point out.
Ann Fam Med. 2015;13:343-346. Full text
Emergency Room Treatment of Marijuana Psychosis
Marijuana is a commonly used drug. In some states it is legal. The following article appeared in the Western Journal of Emergency Medicine, and it describes the correct approach and standard of practice in the treatment of marijuana overdose resulting in psychosis in the emergency department. The citation is noted at the bottom of the article.
Abstract and Introduction
We use a case report to describe the acute psychiatric and medical management of marijuana intoxication in the emergency setting. A 34-year-old woman presented with erratic, disruptive behavior and psychotic symptoms after recreational ingestion of edible cannabis. She was also found to have mild hypokalemia and QT interval prolongation. Psychiatric management of cannabis psychosis involves symptomatic treatment and maintenance of safety during detoxification. Acute medical complications of marijuana use are primarily cardiovascular and respiratory in nature; electrolyte and electrocardiogram monitoring is indicated. This patient's psychosis, hypokalemia and prolonged QTc interval resolved over two days with supportive treatment and minimal intervention in the emergency department. Patients with cannabis psychosis are at risk for further psychotic sequelae. Emergency providers may reduce this risk through appropriate diagnosis, acute treatment, and referral for outpatient care.
Already the most commonly used illicit drug in the United States, marijuana (or cannabis) is becoming more widely used and more potent with expanded legalization.[1–3] Legalization has also popularized "edible" forms of marijuana, including teas and food products. Although often portrayed as a harmless drug with potential therapeutic uses, marijuana has detrimental effects on brain development, psychiatric health (eg, psychosis, schizophrenia, depression and anxiety), lungs (eg, chronic bronchitis and lung cancer) and heart (eg, myocardial infarction and arrhythmias). Public perception of these risks decreases with legalization, and no guidelines exist to help patients gauge the personal safety of use.[4,5] As emergency providers treat more patients with cannabis use disorders, they must educate patients about these chronic health risks and also manage the acute medical and psychiatric complications of marijuana intoxication.
To illustrate the management of acute complex marijuana intoxication and psychosis, we present a case of a woman requiring prolonged emergency department management after ingestion of edible tetrahydrocannabinol (THC), the active ingredient in marijuana.
A 34-year-old woman with no significant psychiatric history presented to the emergency department (ED) with erratic and disruptive behavior. She broke into a neighbor's home, requesting to "go to heaven." She feared people were stealing from her and that "something bad" was going to happen. She reported insomnia, racing thoughts, and euphoria for the past week.
Upon arrival to the ED, her vital signs were temperature of 36.4°C, heart rate of 96bpm, blood pressure 148/111mmHg, and respiratory rate of 11. She was difficult to redirect and her mental status revealed a thin, "nervous," well-groomed woman with a labile affect and pressured speech. The patient's thought process was loose and disorganized with thought blocking. She was paranoid, grandiose, hyper-religious, and endorsed auditory hallucinations. She denied suicidal or homicidal ideation. Her attention and memory were considered impaired though not formally tested.
The patient admitted to using cannabis lip balm and consuming edible cannabis chocolate bars daily over the past week, most recently the day of presentation. She could not quantify her consumption. She believed her paranoia and insomnia onset coincided with her THC ingestion last week. The patient denied other recent substance or alcohol use. She denied any falls or history of traumatic brain injuries. A friend of the patient confirmed this history. Her other medications included propranolol 20mg twice a day for hypertension and infrequent sumatriptan as needed for migraines. Family history of mental illness was unknown since the patient was adopted.
For this presentation of acute psychosis, emergency medical providers conducted a comprehensive work-up to exclude organic etiologies of psychosis or concurrent medical morbidity. A basic metabolic panel was significant for a potassium level of 3.2mg/dL (reference range: 3.5–5.0); her electrocardiogram (EKG) demonstrated a prolonged QTc of 508ms, a pulse of 86, and no U waves or T wave changes. A 9-carboxy-THC level was over 500ng/mL; her urine toxicology screen was negative for cocaine, amphetamines, benzodiazepines, and opioids. A B12 level was elevated at 1186pg/mL. Her complete blood count and a noncontrast head computerized tomography (CT) study were unremarkable.
The patient refused supplemental potassium, and it was thought that her EKG findings did not warrant emergent, forcible repletion. She also removed her intravenous line while agitated. She was placed in two-point soft restraints for her safety. After consultation with psychiatry, the patient was deemed medically appropriate for transfer to the ED's psychiatric emergency service (PES) for further evaluation and treatment.
In the PES, the patient was hypersexual, hyperactive, and intrusive, entering other patients' rooms and touching them. As she could not be safely re-directed, physical restraints were again ordered for the patient's and others' safety. Risperidone 0.5mg PO q6hr and lorazepam 1mg PO q6hr were ordered as needed for management of psychosis and anxiety; the patient required one dose of each during her PES stay.
Twenty-four hours after presentation, her psychotic symptoms and anxiety persisted: she suggested that her food was poisoned and asked whether she was African-American (though she was Caucasian). The patient claimed to have forgotten her father's name, did not know where she was currently living, and was oriented only to person and place. She received her scheduled propranolol for hypertension and 40meq of oral potassium chloride (which she had earlier refused). Her consciousness and attention were intact.
Forty-eight hours after presentation, the patient's paranoia and hallucinations improved dramatically. The patient was able to reflect on the unreality of her paranoia and "odd thoughts" of being African-American. With improved insight, she confirmed heavy use of multiple edible THC products in addition to frequent coffee and energy drink consumption, which she had difficulty quantifying. The patient was diagnosed with cannabis-induced psychotic disorder and severe marijuana use disorder; she was instructed to follow up with outpatient mental health to ensure resolution of her psychosis and begin substance abuse treatment.
New-onset psychosis is a medical emergency with a broad differential. Signs and symptoms concerning for a medical etiology of psychiatric symptoms include abnormal vital signs, altered consciousness, or lack of prior psychiatric history in a patient over 40 years old. The acute onset of symptoms with marijuana use, high serum marijuana metabolite levels, and symptomatic resolution with detoxification suggest these symptoms were secondary to marijuana use.
Cannabis-induced psychotic disorder ("cannabis psychosis") is diagnosed when psychotic symptoms persist beyond acute intoxication and may require clinical management. Psychiatric symptoms include paranoia, derealization, disorganized thinking, persecutory and grandiose delusions, hallucinations, and cognitive impairment. Patients pose a danger to others and themselves due to their altered sense of reality. Safe cannabis detoxification typically requires 24 hours, but sometimes longer for patients with unstable vital signs and persistent psychosis. Benzodiazepines are recommended for agitation related to stimulant intoxication – unless psychosis is present, in which case oral atypical antipsychotics are considered first-line.
Cannabis blood levels reflect the extent and chronicity of marijuana use. A free THC level below 3ng/mL (μg/L) suggests occasional consumption (≤1 joint/week) while a concentration higher than 40ng/mL corresponds to heavy use (≥10 joints/month). Levels above 10ng/mL impair motor function, leading two states with legal recreational marijuana to establish the legal limit for driving at 5ng/mL. In clinical practice, measuring an inactive metabolite of THC, 9-carboxy THC, is preferred due to the rapid decrease in free serum THC levels. In a prior case report, oral cannabis-induced psychosis resolved within 24 hours after recorded serum THC levels below 20ng/mL, or 9-carboxy-THC levels below 50ng/mL; the authors suggested that oral administration may not achieve high serum THC levels. Our patient's 9-carboxy-THC level over 500ng/mL demonstrates that oral administration can achieve high serum THC levels and suggests a dose-response relationship between serum metabolite levels and the severity of psychosis. Moreover, serum drug levels may anticipate a patient's clinical course.
The medical risks of acute cannabis use are primarily cardiovascular in nature. THC enhances sympathetic tone, thereby increasing heart rate and blood pressure. Marijuana increases the risk of myocardial infarction within one hour of use, and cardiovascular events have been reported in otherwise healthy patients.[5,14,15] A Norwegian autopsy study suspected THC-induced arrhythmias (including ventricular tachycardia and fibrillation) as the culprit in six patients who died suddenly.[15,16] Electrocardiograms should be obtained for patients with severe cannabis intoxication; telemetry monitoring may be considered for patients with known cardiac pathology.
Electrolyte abnormalities reported in marijuana users contribute to this cardiac pathology. Chronic marijuana users have lower serum sodium and potassium than non-users. The heavy consumption of carbohydrates while intoxicated leads to an increase in serum insulin levels, driving potassium into cells and causing serum hypokalemia. This hypokalemia can produce reentrant arrhythmias by decreasing conductivity and increasing the resting membrane potential, duration of the action potential, and duration of the refractory period. EKG changes include the decrease in T-wave amplitude, presence of U waves and a prolonged QTc. This patient's very high THC metabolite level, prolonged QTc, and hypokalemia increased her risk for an arrhythmia. The hypokalemia observed in this case was likely related to acute intracellular potassium shifts superimposed on chronic hypokalemia.
Clinicians must manage other, non-vascular risks of acute marijuana use. Respiratory symptoms include shortness of breath, wheezing, and even respiratory failure when marijuana has been smoked "wet" with phenylcyclidine or embalming fluid.[20,21] Patients with pre-disposing genetic vulnerabilities may develop hypokalemic periodic paralysis. And, marijuana use correlates with fatal motor vehicle collisions – clinicians should educate patients and ensure a safe transportation plan on discharge.
Patients with toxic ingestion must be screened for co-ingestion. The persistence and intensity of the patient's symptoms warranted consideration of multiple involved substances. Co-ingestion may also be signaled by an abnormal osmolar or anion gap, positive urine toxicology screen, or QTc or QRS prolongation (Only QTc prolongation was present here).[23,24] However, in many cases, the presence of co-ingestion may only be detected once the patient is able to provide a reliable history. In this case, an elevated B12 level was found on work up of the patient's psychiatric symptoms and suspected to have been caused by energy drink consumption; only later did the patient confirm this suspicion. By its effects on mesolimbic dopamine activity, caffeine may precipitate psychosis, exacerbate chronic psychosis, or worsen affective lability and mood states.[25–28] This patient's high THC metabolite level and medical course are consistent with cannabis psychosis; however, we cannot exclude excessive caffeine use as a contributor to this presentation.
What is this patient's prognosis? Marijuana correlates with the onset of psychosis in patients with schizophrenia and perhaps bipolar disorder as well.[29–32] About half of patients with cannabis psychosis will later be diagnosed with a primary psychotic disorder.[8,33] This high rate may reflect high rates of marijuana use among patients with schizophrenia. Younger age, greater frequency of marijuana use, family history of psychosis, trauma history, and schizotypal personality correlate with higher risk of a later diagnosis of primary psychosis. ED providers can mitigate the risk of psychopathology by addressing the patient's substance use disorder. Safe detoxification is a primary goal and was accomplished here; brief interventions like motivational interviewing and referral for treatment in the ED may reduce use on discharge.[34,35]
- Choo EK, Benz M, Zaller N, et al. The impact of state medical marijuana legislation on adolescent marijuana use. J Adolescent Health. 2014;55(2):160–166.
- Volkow ND, Baler RD, Compton WM, et al. Adverse health effects of marijuana use. N Engl J Med. 2014;370(23):2219–2227.
- Sevigny EL, Pacula RL, Heaton P, et al. The effects of medical marijuana laws on potency. Int J Drug Policy. 2014;25(2):308–319.
- Schuermeyer J, Salomonsen-Sautel S, Price RK, et al. Temporal trends in marijuana attitudes, availability and use in Colorado compared to non-medical marijuana states: 2003–11. Drug Alcohol Depend. 2014;140:145–155.
- Rezkalla SH, Sharma P, Kloner RA. Coronary no-flow and ventricular tachycardia associated with habitual marijuana use. Ann Emerg Med. 2003;42:365–369.
- Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus statement of the American association for emergency psychiatry project BETA medical evaluation workgroup. Western J Emerg Med. 2012;13(1):3–10.
- Sood, TR, McStay CM. Evaluation of the psychiatric patient. Emerg Med Clin North Am. 2009;27(4):669–683.
- Radhakrishnan R, Wilkinson ST, D'Souza DC. Gone to pot - a review of the association between cannabis and psychosis. Front Psychiatry. 2014;5:1–24.
- Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: consensus statement of the american association for emergency psychiatry project BETA psychopharmacology workgroup. Western J Emerg Med. 2012;13(1):26–34.
- Fabritius M, Favrat B, Chtioui H, et. al. THCCOOH concentrations in whole blood: are they useful in discriminating from heavy smokers? Drug Test Anal. 2014;6(1–2):155–63.
- Sharma, P, Murthy P, Bharath MM. Chemistry, metabolism, and toxicology of cannabis: clinical implications. Iran J Psychiatry. 2012;7(4):149–156.
- Favrat B, Menetrey A, Augsburger M, et al. Two cases of "cannabis acute psychosis" following the administration of oral cannabis. BMC Psychiatry. 2005;5:17.
- Aryana A, Williams MA. Marijuana as a trigger of cardiovascular events: Speculation or scientific certainty? Int J Cardiol. 2007;118(2):141–144.
- Mittleman MA, Lewis RA, Maclure M, et al. Triggering myocardial infarction by marijuana. Circulation. 2001;103:2805–2809.
- Charles R, Holt S, Kirkham N. Myocardial infarction and marijuana. Clin Toxicol. 1979;14(4):433–438.
- Bachs L, Morland H. Acute cardiovascular fatalities following cannabis use. Forensic Sci Int. 2001;124:200–203.
- Osadolor HB, Emokpae AM. Effects of marijuana on sodium and potassium ions homeostasis among smokers in benin city - a metropolitan city in nigeria. International Journal of Pharma and Bio Sciences. 2010;1(3):1–3.
- Feldman ML, Hadfield S. Pot paresis: marijuana and a case of hypokalemic periodic paralysis. J Emerg Med. 2009;36(3):236–238.
- Helfant, RH. hypokalemia and arrhythmias. Am J Med. 1986;80(4):13–22.
- Lutchmansingh D, Pawar L, Savici D. Legalizing cannabis: a physician's primer on the pulmonary effects of marijuana. Curr Respir Care Rep. 2014;3(4):200–205.
- Gilbert CR, Baram M, Cavarpocchi NC. "Smoking west": respiratory failure related to smoking tainted marijuana cigarettes. Tex Heart Inst J. 2013;40(1):64–67.
- Asbridge M, Hayden JA, Cartwright JL. Acute cannabis consumption and motor vehicle collision risk: systematic review of observational studies and meta-analysis. BMJ. 2012;344.
- Holstege C, Borek H. Toxidromes. Crit Care Clin. 2012;28:479–498.
- Mokhlesi B, Leiken JB, Murray P, et al. Adult toxicology in critical care – part I: general approach to the intoxicated patient. CHEST. 2003;123:577–592.
- Nehlig A, Daval JL, Debry G. Caffeine and the central nervous system: mechanisms of action, biochemical, metabolic and psychostimulant effects. Brain Res Brain Res Rev. 1992;17(2):139–169.
- Hedges DW, Woon FL, Hoopes SP. Caffeine-induced psychosis. CNS Spectrum. 2009;14(3):127–129.
- Shaul PW, Farrell MK, Maloney MJ. Caffeine toxicity as a cause of acute psychosis in anorexia nervosa. J Pediatr. 1984;105(3):493–495.
- Szpak A, Allen D. A case of acute suicidality following excessive caffeine intake. J Psychopharmacol. 2012;26(11):1502–1510.
- Moore THM, Zammit S, Lingford-Hughes A, et al. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet. 2007;370(9584):319–328.
- Large M, Sharma S, Compton MT, et al. Cannabis use and earlier onset of psychosis: a systematic meta-analysis. Arch Gen Psychiatry. 2011;68(6):555–561.
- Gibbs M, Winsper C, Marwaha S, et al. Cannabis use and mania symptoms: a systematic review and meta-analysis. J Affect Disord. 2014;171C:39–47.
- Bally N, Zullino D, Aubry JM. Cannabis use and first manic episode. J Affect Disord. 2014;165:103–108.
- Arendt M, Rosenberg R, Foldager L, et al. Cannabis-induced psychosis and subsequent schizophrenia-spectrum disorders: followup study of 535 incident cases. Br J Psychiatry. 2005;187:510–515.
- Woodruff SI, Eisenberg K, McCabe CT, et al. Evaluation of california's alcohol and drug screening and brief intervention project for emergency department patients. West J Emerg Med. 2013;14(3):263–270.
- Magill M, Barnett NP, Apodaca TR, et al. The role of marijuana use in brief motivational intervention with young adult drinkers treated in an emergency department. J Stud Alcohol Drugs. 2009;70(30):409–413.
Western J Emerg Med. 2015;16(3):414-417. © 2015 Western Journal of Emergency Medicine
Surprising and Perplexing Med-Legal Verdicts
A recent article by Dr. Segal in Medscape discusses two defensible cases that resulted in surprising horrific outcomes for the two doctors who were sued. There is a take home message and lesson to be learned embedded in these two cases.
How Would You Have Handled Patients Like These?
Being sued for malpractice is a traumatic experience. The odds of being sued at least once over one's career are high. Doctors typically have sufficient professional liability coverage to prevent financial loss. But not all cases get resolved as expected, and doctors may end up with unforeseeable financial loss.
In addition, disciplinary action by a state medical board can also result in onerous remediation, the cost of which can also be surprisingly steep.
It's one thing when a physician clearly did something wrong and as a result suffers the consequences. But what if the wrongdoing isn't clear-cut—yet the financial hit to the doctor is still severe? Consider two unusual cases in point.
Did This Doctor Instruct His Patient?
In 2012, a Georgia jury awarded $3 million dollars to the estate of William Martinez. Martinez was 31 years old when he entered his cardiologist's office. He complained of chest pain radiating into his arm. His cardiologist noted that Martinez was at "high risk" of having coronary disease and ordered a nuclear stress test. The test was scheduled to take place 8 days later.
The day before his test, however, Martinez apparently engaged in some "exertional activity." He participated in a threesome with a woman who was not his wife and a male friend. While in the midst of this three-way sexual experience, Martinez died. Naturally, his family then sued the cardiologist, arguing that no instruction to avoid exertional activity had been given. The family's rationale was that had Martinez been properly instructed to avoid high-risk activities, he would have complied.
During the trial, the cardiologist alleged that Martinez was instructed to avoid exertional activity until after the test was completed.
The family initially claimed $5 million in damages, but this claim was reduced by a finding that Martinez was 40% liable for his own death. So the patient was 40% liable; the liability of the doctor was 60%. If the cardiologist's malpractice policy coverage was for the typical $1 million, it probably leaves him $2 million short.
In states that have implemented substantive tort reform, the sizeable award might have been reduced as a matter of law—if a large portion of that award was attributable to "pain and suffering." In 2010, however, the Georgia Supreme Court overturned that state's law, which set a $350,000 limit on damages paid out for pain and suffering in medical malpractice cases. It ruled that the 5-year-old Georgia law violated a person's constitutional right to trial by jury and a plaintiff's right to allow a jury to calculate noneconomic damages as it sees fit.
That prior decision has concrete implications for physicians—particularly given that most doctors carry only $1 million in malpractice coverage. As such, understand what your policy limits are if you are sued; assess the likelihood that a judgment will exceed those limits in a particular case if you lose; and see whether limiting your downside risk while still allowing you to have your day in court would be helpful, an option discussed next.
Hedging Your Risk if You Go to Court
The patient died young, with decades of unrealized earning capacity. For the physician being sued, this means that if the plaintiff wins, there is a sizable chance of a multimillion-dollar award. Juries are unpredictable. How can a doctor protect himself against a financially crippling judgment when the alternative is to give the carrier permission to pay an amount up to and including the policy limits?
The answer is a high/low agreement. A high/low agreement allows the doctor to both have his day in court and potentially be vindicated with a verdict of "not liable," without having his carrier simply pay the plaintiff an amount up to and including his policy limits (a tacit admission of liability) and not risking his entire nest egg should he lose the judgment.
In a high/low agreement, the each side agrees that there is risk to their case. A doctor may be concerned that an injured patient (such as someone in a wheelchair) will elicit a strong emotional reaction from a jury when testifying about an expensive life-care plan. Or a young widow with little earning capacity may likewise generate sympathy with a jury when they learn that her children will not be able to afford college. Such judgments could be as high as $10 million and bankrupt a doctor.
On the other hand, a plaintiff may be concerned that although the injury was great, the doctor did not violate the standard of care—and even if he did, the doctor's actions did not cause the injury. If the jury agrees, the plaintiff may get nothing.
A contractual high/low agreement between both parties can create settlement "bookends" of, say, $100,000 and $1 million. The doctor gets his day in court. The jury renders its verdict. But each side hedges its risk. If the jury says the doctor is liable for $10 million, the doctor only has to pay the "high" value—or $1 million, typically his policy limit. If the jury finds the doctor not liable, the plaintiff still gets something—in this example, $100,000. In addition, because the jury finds the doctor not liable, there's no report to the National Practitioner Data Bank.
Because there was no way to prove whether the cardiologist had properly advised his patient—because the advice was not documented, it was the doctor's word against that of the family of the deceased—the jury could just as easily have found for 100% for the plaintiff or 100% for the defendant. Given this possibility, a high/low strategy might have helped mitigate risk for the cardiologist.
If you are in a situation with a potentially catastrophic payout, consider bringing up the possibility of this arrangement with your carrier.
Was This Surgeon "Grossly Negligent"?
On December 4, 2010, at 11:47 AM, a patient was admitted to the emergency department (ED) of a hospital in California's Bay Area with a self-reported history of having inserted a bottle into his rectum 2 days earlier. He was in pain and had gone 2 days without a bowel movement. A physician assistant documented distention and diffuse tenderness. A plain abdominal radiograph showed a glass bottle in the mid-pelvis. There was no free air, although the patient was in the supine position.
The surgeon arrived at 2:11 PM and ordered 25 μg of fentanyl for pain.
What happened next resulted in a complaint to the California Board of Medicine. An interview with the surgeon by a board investigator provided the details. The surgeon explained that she had given the patient two options: He could have the bottle removed surgically, or it could be extracted manually in the ED. The surgeon stated that the patient chose the ED route because he did not want to lose his new job. (It is unclear whether this decision was related to a longer perceived recovery time if he had surgery, a higher bill for a surgical procedure, or something else.)
During the interview, the surgeon said that she could feel the bottom of the bottle with one finger but could not move it at all. However, the history and physical documented something else: The surgeon "was able to palpate the bottle and was able to manipulate the bottle and move the foreign body around but was unable to rectally extract it."
During the first part of her interview, the surgeon stated that she placed her hand into the rectum to remove the bottle while the patient pushed.
Nursing notes indicated that the surgeon placed her arm into the rectum up to her bicep, and the patient was screaming in pain. This same nurse said the surgeon did not want the patient to receive any additional pain medication, because she needed the patient conscious for him to help push the bottle out.
The surgeon then performed a rigid sigmoidoscopy, which showed the sigmoid colon to be dusky and swollen. A new abdominal radiograph suggested perforation. The patient was taken to an operating room (OR) for a laparotomy.
The board of medicine detailed its parade of horribles:
- Gross negligence: Excessive force while attempting to remove the bottle demonstrated disregard for patient safety and departure from standard of care or incompetence.
- Gross negligence: The decision to continue with the procedure in the ED without securing appropriate assistance from nursing staff demonstrated disregard for patient safety and constituted extreme departure from the standard of care.
- Repeated negligent acts: Inadequate sedation during attempts to manually extract the bottle constituted departure from the standard of practice.
- No informed consent and substandard documentation of procedure note.
- No "timeout" was performed before starting the procedure. [Author's note: It's unclear whether the timeout would have been used to verify that the correct patient was about to undergo a procedure, or to confirm that the procedure addressed the correct side of the rectum.]
- Dishonesty: There are multiple story lines—was a finger, hand, or arm involved? Was the bottle mobile, or not mobile?
The penalty the board imposed:
- 25 hours a year (for each year of probation) of education addressing the deficiencies outlined in the complaint.
- Complete an approved course on professionalism—at the surgeon's expense, and in addition to other continuing medical education (CME) requirements.
- Complete an approved course on medical record-keeping—at the surgeon's expense, and in addition to other CME requirements.
- License revoked, but revocation temporarily suspended and surgeon's license placed on probation for 3 years as long as she has no further infractions.
- The surgeon will pay the costs of monitoring her probation—currently set at $3999 per year—for each year of probation.
The surgeon was licensed to practice in Ohio as well as California. The Ohio Medical Board learned of the California board's imposed discipline. The Ohio Board wrote to the surgeon stating that it was investigating whether to impose discipline in Ohio as well. The board gave her 30 days from the date of mailing to request a hearing. That deadline was May 12, 2014.
The board received the surgeon's letter on May 15, 2014, and that letter did not include a request for a hearing. (The record is silent on what information the letter did contain. Presumably, it was an explanation of the surgeon's treatment of the case, or why she failed to respond to the Ohio board in a timely manner.)
The board revoked her license.
Ignore a State Licensing Board at Your Peril
Many doctors have licenses in more than one state. Discipline in one state often triggers discipline in another state. Most, if not all, licensing boards mandate that the licensee has an affirmative obligation to notify them of discipline in any other venue (for example, another state, the Centers for Medicare & Medicaid Services, or the US Drug Enforcement Administration) within a couple of weeks of the disciplinary action.
Most disciplinary actions are reportable to the National Practitioner Data Bank, which means that the boards of the state or states in which you are licensed will eventually learn about these actions. If you address such an action proactively, it's considered an "explanation." If you address it after it's discovered by a board, without prior notification by you first, it's considered an "excuse."
As such, if you hear from a licensing board, don't ignore it. Most of the time, they are just looking for your side of the story. Statistically, you are likely to prevail. But if you miss a deadline to respond, you will have wasted an opportunity. Make sure that you respond in a timely manner and document that you sent your response by certified mail with return receipt requested, or by FedEx or UPS with a tracking number. Not all boards will impose the same penalty as the first board. Some boards may rule the opposite of the first board.
There are times and reasons for doing a procedure in the ED instead of the OR: timeliness, OR availability, cost, and patient preference. Whatever the rationale, make sure the record supports your thinking. In this case, the surgeon was on the defensive from the beginning because the record was sparsely documented.
Next, it's okay to stop a procedure if you're not succeeding. The patient may tolerate some amount of pain if the anticipated outcome is a near-term success. At some point, however, that strategy may change—and then it's time to go to the OR. A common manifestation of that strategy is a trial of labor that turns into cesarean section.
The attending nurse's story was dramatically different from the surgeon's story. The nurse documented her story. It's hard to believe that the surgeon was able to place her arm (up to the bicep) into the patient's rectum. But there was no competing narrative in the chart.
Finally, the penalty seems steep both in cost and time. The question is how and why this matter evolved into a board complaint. Perhaps it was a dispute over a residual bill, poor communication, or verbal sparring with the nurse that escalated into score-evening retribution. The record of the case doesn't address these issues.
The Moral: Take Steps to Limit Your Risk
Even when doctors diligently care for their patients, they may be exposed to unexpected liability. If a patient's outcome is poor, judgment at trial may well exceed policy limits. Proper documentation of the medical record and timely responses to board complaints are the best ways to prevent a gray-zone set of facts from evolving into formal discipline by a medical board.
Published in Medscape: 2015, Dr. Segal