Dr. Gustin's Blog

Emergency Rooms See Energy Drink Overdoses

With increasing frequency over the past 2 years, emergency departments have witnessed a sharp spike in visits related to energy drinks especially amongst teenagers.  These drinks are high in caffeine, sugar, and other herbal stimulants.  When combined with alcohol or illicit drugs, overdoses occur.  Read the article explaining the sharp increase of cases as well as the problems associated with this particular type of overdose.

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Problems Arising From Poor Patient Communication

Medical malpractice lawsuits frequently arise because of misundertandings, poor communication, and the reactive emotions that naturally follow. When patients become angry, they are apt to escalate the situation, magnify the problems or bad outcomes, and become predisposed to blaming the doctor or the hospital. Much litigation can be avoided if situations are de-escalated early.

There are ways to deal with such encounters in which you work with the angry patient and guide them through their emotions, and the accompanying volatility, to the point where it is possible to have a constructive, or at least manageable discussion with them.

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Can Vitamin Supplements Cause Death?

The following article is from a recent issue of Medscape. Vitamin supplements are ubiquitous and are commonly taking by people who want to be health conscious and maximally healthy. But not all vitamins and minerals are benign. The Medscape summarizes a recent study in the Archives of Internal Medicine. The citation appears at the end of this report. The study has serious public health implications.

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Substance Abuse: New DEA Emergency Ban for Bath Salts

Recently the DEA took emergency action to ban for one year bath salts that are composed of PABS, methylenedioxypyrovalerone, which is structurally and toxicologically related to pyrovalerone and a-pyrrolidinophenone compounds that inhibit norepinephrine-dopamine reuptake and act as central nervous system stimulants.  These salts are deadly, and are sold under the brand names:  Ivory Wave and Vanilla Sky.

Users take it orally, intranasally, intravenously, or rectally and achieve a high that is similar to methamphetamine.  It enhances alertness, increases energy, and is an aphrodisiac.  On the street, it is being called "legal cocaine".  

Doses as low as 3-5 mg will produce an effect.  The average dose ranges from 5 to 20 mg, and the risk for overdose is high because packages contain up to 500 mg.  In fact, it was the increase in overdose, emergency room visits, and death that prompted the DEA to take action.  Orally, absorption is rapid, and the rush (euphoria) that is produced peaks at 1-2 hours after ingestion, and the total effect lasts about 3-4 hours.

The physical effects of PABS include tachycardia, hypertension, arrhythmias, hyperthermia, seizures, stroke, myocardial infarction, and even death. Behavioral and mental effects include panic attacks, anxiety, paranoia, hallucinations, psychosis, aggressive or violent behavior (such as self-mutilation, suicide attempts, and homicidal activity), insomnia, anorexia, and depression.

Emergency treatment consists of benzodiazepams for sedation and IV fluids to prevent hypercatabolic rhabdomyolysis.  Metabolic acidosis, if present, is treated in the usual manner.

Click Here:  to obtain the New England Journal of Medicine article in PDF format

A Vaccine for Substance Abuse?

Can you imagine a vaccine that would eliminate smoking, cocaine, methamphetamine, heroin or opiate use?  Researchers are tantalizingly close to developing a vaccine that would permanently block those receptors that when stimulated by these and other substances of abuse provide the addictive euphoric and mind-altering effects.

Addicts would no longer be able to use and enjoy the effects of the substances they abuse.  The research is being headed by Dr. Janda at Scripps Research Institute.

To read the full NY Times article:  Click Here

Medical Malpractice Lawsuits Sometimes Come When They Are Least Expected

According to the American Medical Association, more than 42% of physicians have been sued for medical malpractice over their careers, and more than 20% were sued at least twice.  What causes medical malpractice lawsuits, and how can they be prevented?

Most physicians are taken by surprise when they received a summons alleging that their negligence had injured or killed a patient. Most assume that although the patient was injured they would not be sued.  Other might have lost the patient in follow-up and had no idea that anything was wrong until they were sued.  In other cases, physician who are sued might not have even seen the patient.  Rather, they may have been consulted in a brief phone call.

In other instances, physicians who were surprised by a lawsuit should have seen it coming. They missed that in the context of an unexpected adverse health outcome, their patient was unhappy.  Many are oblivious to how patients were lost in follow-up or how their own behavior may have provoked the lawsuit.

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Medical Malpractice Risks When Undertreating and Overtreating

Doctors are facing a catch 22, that in my view will result in greater medical malpractice risk for a practicing physician.  With medical costs skyrocketing, managed care struggling, and legislative pressures to effect price controls, doctors are now required to make cost a primary factor in their decision making processes when evaluating and treating patients.

Overtreatment may be bad for healthcare costs, but doctors are now moving too far in the other direction--undertreatment. Managed care organizations (MCOs), accountable care organizations (ACOs), and other new payment forms designed to lower costs are regularly exerting pressure on doctors to avoid various tests and procedures. Government, hospital, or insurance companies have developed systems that now monitor the physician's practice, and now "pressure" physicians to do less costly testing and fewer treatments and procedures.

However, this has created a situation where the physician is faced with increased iability if a diagnosis is missed.  Moreover, the patient is put at risk as well.  The danger to the patient is in missing the diagnosis or in failing to offer the best treatment. And of course, the physician can be sued for malpractice for failure to diagnose or treat properly. Doctors are held to the standard of care of the reasonable physician in his specialty at the time of the treatment regardless of financial demand by third party payers, MCOs, or the newly proposed ACOs.

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Why Defensive Medicine Is Here to Stay

For the past 35 years individual states have been addressing the problem of medical malpractice lawsuits in disparate ways with varying degrees of success. Lately, physicians have partnered with legislators and lawmakers to address skyrocketing medical malpractice insurance premiums.  So far, little has been accomplished.  Until the situation is rectified, if it will ever be, physicians will continue to do whatever is necessary to avoid malpractice exposure. 

The primary tactic used by physicians to avoid medical malpractice lawsuits is defensive medicine. In addition to enormous malpractice premiums, over $200,000 annually for some surgical specialities, that continue to increase year after year, the practice of practicing defensively has also saved insurance companies a lot of money. Physicians are avoiding lawsuits but still must pay exorbitant premiums. Insurance companies are the beneficiaries of this.  Any objective analysis of the problem would conclude that the entire system is dysfunctional.  And there are no easy solutions.

So rather than try to address the solution to a seemingly unsolvable problem, let's talk about one spinoff to this problem: defensive medicine.

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A new test for Stevens Johnson Syndrome

All emergency physicians have made the dreaded consult call to the dermatologist: "Patient with drug eruption, rule out Stevens-Johnson syndrome." Although adverse cutaneous drug eruptions are common, Stevens-Johnson syndrome (SJS) and its more severe variant, toxic epidermal necrolysis (TEN), are fortunately rare. These extensive mucocutaneous blistering drug eruptions are associated with significant morbidity, even death. In the case of TEN, mortality rates may exceed 20%.

In the past, the condition was easy to miss, and the consequences were often catastrophic.  Many a medical malpractice lawsuit has been filed on account of this missed diagnosis.  Medical expert witnesses from the fields of emergency medicine and dermatology have testified for and against plaintiffs whose families survived them, or who were left with dire and permanent health effects.  The diagnosis is not always apparent, but unfortunately the condition is often fulminant.   Less than a day can pass between discharge home and a full blown desquamating rash.

Now for the first time, there is a new test that will diagnose the condition before it has advanced to a critical stage.

Intervention for full-blown SJS and TEN consists primarily of supportive measures such as management in a burn unit (for TEN), prophylaxis against infections, correction of fluid and electrolyte imbalances, and prevention of stricture formation and ocular complications. Recently, intravenous immunoglobulin therapy has shown promise as an early intervention, potentially arresting progression of SJS and TEN if administered early enough. In this context, early detection of SJS/TEN might greatly improve clinical outcomes.

Granulysin, a cytotoxic lipid-binding protein that induces cell apoptosis, is found in high concentrations in blister fluid from patients with SJS/TEN.  Recently, Abe and colleagues found significantly elevated serum granulysin levels in patients with SJS/TEN.  Intriguingly, these elevated levels occurred before the development of skin and mucosal detachment and dropped rapidly within 5 days of disease onset, suggesting that serum granulysin may be a useful marker for the early phase of SJS/TEN.

Inspired by these preliminary data, Fujita and colleagues developed a simple rapid immunochromatographic test for elevated serum granulysin. This test is completed in only 15 minutes and yields a clinically visible result line at a threshold of 10 ng/mL of serum granulysin.

In order to gauge the sensitivity and specificity of this novel screening test, Fujita and colleagues tested serum samples from 5 patients with clinically confirmed SJS/TEN. The samples were taken early in the disease progression (ie, 2-4 days before development of mucocutaneous erosions). For comparison, serum samples were taken from 24 patients with non-SJS/TEN drug eruptions, defined in this study as "ordinary drug-induced skin reactions" (ODSRs), and 31 healthy controls. Interestingly, 4 of the 5 serum samples from SJS/TEN patients showed positive bands, whereas only 1 of the 24 samples from patients with ODSRs and none of the controls showed positive bands. Test sensitivity was 80% and specificity was 95.8% for SJS/TEN vs other drug eruptions.


If future larger studies confirm that this screening test is both sensitive and specific for SJS/TEN, then it should see immediate clinical use.

Of note, because serum granulysin levels peak before the onset of mucocutaneous erosions and decline as the disease progresses, the absence of a positive test will not be enough to rule out SJS/TEN. Hence, the serum granulysin rapid screening test should be most useful in identifying the subset of drug eruptions that are most likely to progress to SJS/TEN. Once this subgroup is identified, closer clinical monitoring and a lower threshold for initiating intravenous immunoglobulin therapy may be warranted.

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