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Teaching Hospital Update - January 11-15, 2010


Email Alert

January 15, 2010

By Jennifer Viegas*

Facilities Reach Settlement on Medicine Disposal

New York Attorney General Andrew Cuomo reached settlements with two critical-access hospitals and three nursing homes that he alleges had been dumping pharmaceuticals down their drains and into the watershed that supplies drinking water to nine million residents of New York and four surrounding counties.

The settlements stem from an investigation, described in a news release as broad and ongoing, into the pharmaceutical waste-management procedures at New York hospitals, nursing homes, and assisted-living centers. The settling facilities--including sixteen-bed O'Connor Hospital in Delhi, NY, and fifteen-bed Margaretville (New York) Hospital--have agreed to immediately cease allowing pharmaceutical waste into New York waterways and instead send the material to waste-management handlers with appropriate capabilities.

The agreements also call for the facilities to pay civil penalties for past violations, reimburse the state for the investigation, and implement pharmaceutical "take back" programs so that patients do not resort to flushing unused drugs.

Gregg Blesch, Facilities Reach Settlement on Medicine Disposal, Modern Healthcare's Daily Dose (Jan. 12, 2010) (note: registration is required to view this content).

Morphine May Help Traumatic Stress

Doctors have long hoped to discover a "morning-after pill" to blunt the often disabling emotional fallout from traumatic experiences. Now it appears that they have had one on hand all along--morphine.

In a large study of combat casualties in Iraq, Navy researchers reported Wednesday that prompt treatment with morphine cut in half the chances that troops would develop symptoms of post-traumatic stress later on. Other opiates are likely to have similar effects, experts said.

In previous work, researchers had found that larger doses of morphine given to children with severe burns also reduced post-traumatic symptoms, like flashbacks, depression, and jumpiness. These symptoms have become lasting in about one in eight service members returning from Iraq.

The new study, appearing in The New England Journal of Medicine, supports the standard practice in settings like the battlefield and emergency rooms, where morphine is often used readily. But experts say it may have implications for the timing of treatment and for a wider variety of traumas, like those resulting from rape or muggings.

Experts caution that any benefit must be stacked up against the drugs' risks: they are habit-forming with repeated use and can blur memories of events that can be life-changing.

In the new study, researchers at the Naval Health Research Center in San Diego reviewed detailed medical records of 696 troops who had been wounded in Iraq from 2004-2006, determining whether and when morphine was used in treatment. Military doctors used the drug for most serious injuries--generally in the first two hours after the injury--but sometimes administered others, like anti-anxiety medications.

The study found that 243 of the servicemen and women were given a diagnosis of post-traumatic stress within two years of their injury. When the severity of the wounds was taken into account, researchers calculated that the diagnosis was half as common in those who had received morphine as in those who had not. The study noted that age, sex, and the cause of injury did not significantly alter the findings.

The drugs appear to blunt the emotional charge of traumatic memories in several ways. Most obviously, they kill the pain when it is most excruciating; often, they scramble the ability to recall what exactly happened. Opiates also inhibit the production of a chemical messenger called norepinephrine, which is thought to enhance fear signals in the brain.

Researchers are not sure how the brain creates what is, in effect, too strong an emotional memory after a frightening experience. It may be that in those first days after the experience, people continually ruminate, reminding themselves, say, how close they came to dying. That thought in turn prompts a release of fear hormones, which further inflame the emotional charge of the memory.

Benedict Carey Morphine May Help Traumatic Stress, N.Y. TIMES,
(Jan. 13, 2010).

Joint Commission Report Notes Quality Gains

Hospital quality as defined by use of thirty-one measures tracked by the more than 3,000 institutions accredited by The Joint Commission continues to improve, although performance was down slightly on two measures.

While Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009 is the fourth edition of The Joint Commission's yearly review of hospital compliance with evidence-based measures shown to lead to the best patient outcomes, it's noted that some of the measures have been tracked for seven years and that five new ones were added in 2008.

Since 2002, the most dramatic improvement has been 58.8 percentage points in both providing pneumococcal vaccinations, to 89% from 30.2%; and offering smoking-cessation advice, to 96% from 37.2%. Two measures fell in 2008: measuring oxygen in blood for pneumonia patients, to 99.7% from 99.8% in 2007; and giving antibiotics to pneumonia patients in the intensive-care unit within twenty-four hours fell to 60.3% from 63.9%.

That last measure was one of two areas highlighted for needing improvement. The other measure is providing heart attack patients with medications for dissolving blood clots within thirty minutes of arrival at the hospital, with only 52.4% of reporting hospitals being in compliance.

Andis Robeznieks, Joint Commission Report Notes Quality Gains, Modern Healthcare's Daily Dose (Jan. 14, 2010) (note: registration is required to view this content).

U.S. Supreme Court Will Not Review Doctor's Lawsuit Alleging Disability Bias

Recently, the U.S. Supreme Court denied review to a physician whose disability discrimination claims against his former employer hospital were dismissed on summary judgment. Dr. Philip Bodenstab, an anesthesiologist at Chicago's Cook County Hospital, was discharged after he allegedly threatened to harm co-workers. Bodenstab sued the hospital under the Americans with Disabilities Act (ADA) and the Civil Rights Act of 1871
(42 U.S.C. § 1983), alleging disability discrimination, failure to accommodate, retaliation, and violation of his First Amendment and due process rights. The U.S. District Court for the Northern District of Illinois ruled in favor of defendants.

The U.S. Court of Appeals for the Seventh Circuit affirmed, saying that Bodenstab had no ADA claim because he could not show that the hospital's decision to terminate him was a pretext for unlawful discrimination. The court said that even if Bodenstab could show that defendants regarded him as disabled in the major life activity of "interacting with others," the county raised a legitimate, nondiscriminatory reason for discharge that the physician could not show was a cover for disability bias.

Bodenstab then filed a petition for a writ of certiorari in the high court. In his petition he argued that the Seventh Circuit erred in affirming a trial court's decision that rejected his claims at the summary judgment stage. The trial court should have allowed him an opportunity to respond to a summary judgment motion filed by defendant Cook County by presenting evidence that defendants violated his due process and free speech rights, he said.

Bodenstab also argued the Seventh Circuit also improperly affirmed a trial court decision that ruled in favor of Cook County Hospital officials without giving him a chance to prove that there was insufficient evidence that he committed misconduct justifying discharge or that their investigation was unfair. The lower courts also prevented him from showing that he was the subject of a "coercive, one-sided hearing" that resulted in a "fabricated report engineered to justify his discharge," the petition said.

The petition did not challenge the appeals court's finding that Bodenstab could not pursue a claim under the ADA.

U.S. Supreme Court Will Not Review Doctor's Lawsuit Alleging Disability Bias, BNA'S HEALTH L. REP. (Jan. 14, 2010) (note: registration is required to view this content).

Toddler Found Frozen in Creek Revives

When Scott Magley, MD, arrived at the scene in December 2008, the twenty-three-month-old toddler was literally a block of ice.

After going missing for at least three hours, she had been found face down in a creek. She had no heartbeat, no response. Her initial core temperature was below the reading limits of Magley's field thermometer. Ice crystals had formed in her mouth.

Magley, a critical care specialist who lives in the countryside near the spot where the Amish child was found, managed to perform endotracheal intubation. He began advanced life support and transported her to the hospital, with multiple doses of epinephrine and atropine administered en route.

On arrival the girl was unresponsive, with fixed and dilated pupils, no palpable pulse and no appreciable cardiac wall movement on ultrasound. Her cardiac rhythm showed asystole.

Over the course of the next two hours, the cardiopulmonary resuscitation Magley had begun in the field continued at the hospital. Passive warming was initiated, but the staff could not do an extracorporeal bypass because the appropriate-sized catheters were not available. Active warming was performed using the Arctic Sun Management System.

Doctors and nurses continued working because they were encouraged that her body temperature appeared to be rising--from a low of nineteen degrees Celsius (66.8 degrees Fahrenheit). Additionally, the girl occasionally opened her eyes and made nonpurposeful arm movements during cardiac compressions.

When her core temperature rose to twenty-six degrees C (seventy-nine degrees F), doctors detected ventricular fibrillation. They administered one electric shock, and regular sinus rhythm returned. That resulted in a palpable pulse and eventually a discernible blood pressure.

She then began to exhibit purposeful movements and appeared to recognize her parents, who had since arrived at the hospital. She was then transferred to Children's Hospital of Pittsburgh when her internal temperature rose to thirty-one to thirty-three degrees C (eighty-eight to ninety-one degrees F).

She was extubated on day one at the hospital and was discharged home on day five, with apparently normal neurological status. On follow up, her parents thought she was having some difficulty in picking up items with either hand, but otherwise did not appear to have any lasting ill-effects.

This case serves as an opportunity to review important concepts in the resuscitation of the profoundly hypothermic patient and to emphasize the resiliency of quickly cooled tissue, deprived of perfusion but before hypoxia damages cellular mechanisms involved in recovery.

Ed Susman, Toddler Found Frozen in Creek Revives, MedPage Today (Jan. 13, 2010).

*We would like to thank Jennifer P. Viegas, Esquire (Hall Render Killian Health & Lyman PC, Troy, MI), for providing this week's update.

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