SHE SLEPT WITH AN OPHTHALMOLOGIST WHO KEPT ASKING, "IS IT BETTER LIKE THIS, OR LIKE THIS?"

The eye surgeon went home after a busy day in the operating room where all the surgeries were smooth and uneventful. The following day the post-op patients were all suffering with corneal edema, diffuse anterior inflammation, and perhaps even fibrin or hypopyon in the anterior chamber. The condition is called toxic anterior segment syndrome (TASS), and the cause can be any of a number of operative problems, most commonly one of the solutions used to irrigate during the surgery. Over 100 cases were reported in the first half of 2006 alone. It can be wrong pH in the balanced salt solution, or epinephrine with preservative used to keep the pupil dilated rather than preservative-free, or gas residue when hand instruments are sterilized with ethylene oxide, or an anti-biotic with wrong concentration injected beneath the conjunctiva at the end of surgery leaking into the eye. It can be catastrophic for both patient and doctor, and determining the exact cause can be complicated and difficult. Stuff happens!

NEVER LET THE DOCTOR TAKE YOUR TEMPERATURE WITH HIS FINGER.

For many years we have had "doc in the box" medical care with clinics usually set up in tourist areas which provide walk-in physician care. They are often frustrating competition for local practitioners, but usually do a fair job for emergency problems. Now we have RBCs, retail based clinics at Wal-Mart and Target stores, caring for patients at the mall or shopping center. The nice part for patients is the ease of seeing a medical person, and the nice part for the clinics is that it is all cash, no insurance forms, no detailed coding baloney, and regular hours. Recently, the American Academy of Pediatrics and the American Medical Association spoke out against RBCs, claiming that medical care is fragmented with poor follow-up and loss of continuity. This is true, of course, but the problem really generates from crowded doctors’ schedules, prolonged waiting in reception areas and delays in getting appointments. So, get used to it, people. It is free enterprise at work at the mall.

"IF WE WANT OUR COMPANY TO SURVIVE AND PROSPER OVER THE LONG TERM, WE MUST GET OUR SHARE OF THE YOUTH MARKET." R. J. Reynolds Inc. 1974

The tobacco people do not sleep. "Snus" is a smokeless tobacco product popular in Scandinavia for decades, but banned in most of Europe as an oral carcinogen. Now R .J. Reynolds is test marketing "Camel Snus" in Portland, Oregon, and Austin, Texas, two communities viewed as "hipster havens." The product is put up in small neat pouches of 20 per tin. They smell of mint tea, taste like gum and come in three flavors, regular, spice and frost, packets that fit inside the mouth. Supposedly, they are spit-free as well as smoke-free. Of course, they are not designed to appeal to youth. Right!! The snuscamel.com website says you can use it at a concert, in a jet plane, even at a crowded up-scale restaurant. How about a teenager in a classroom?

MAN IS THE ONLY MACHINE THAT NEEDS TO BE LUBRICATED WITH ALCOHOL.

The national average for alcohol-related traffic deaths is 39%. Ugly! What is even more ugly is that right here in our Aloha state the figure is actually 51%, twelve full percentage points above the national average, and that places us right at the top (really the bottom) of all 50 states. Only Washington D.C. is ahead of Hawai’i at 54%. Look at the celebrities arrested for DUI, starting with Mel Gibson, comedic actors Rip Torn and Tracey Morgan, and Michelle Rodriguez, who was jailed here for five hours (that’s all) of a sixty-day sentence for repeat DUI, to mention just a few. The sport star arrests would fill up a phone book, including Sacramento Kings head coach Eric Musselman. These are supposed to be responsible citizens. And as a responsible physician, what action do you take (if any) when you detect alcohol on your patient’s breath? Obviously, if the DUI highway slaughter is to be stemmed, the offenders must be jailed, and their drivers’ licenses and auto licenses impounded. A modest fine, a suspended jail sentence and probation are fruitless.

IT’S NOT ENOUGH TO HAVE NEED. FOR MEDICAL CARE IN HAWAI’I, YOU HAVE TO EARN A CERTIFICATE!

The Hawai’i comprehensive health planning law which provides for "certificate of need" (CON) for certain medical expenditures is under severe attack by many citizens on the island of Maui. Ronald Kwon, M.D., Hawai’i born, Harvard educated, and a long-time infectious disease specialist on the island, in partnership with Triad Hospitals (ranked number four by Fortune magazine among America’s most admired health care companies) applied for a CON to build a second hospital in south Maui. The plan has the vigorous support of the Mayor of Maui County, Governor Linda Lingle, many Maui physicians and a large and varied group of people. After a complicated and prolonged application, followed by a stair-step collection of hearings and one re-hearing, the application was denied. Wow!! The passion and animosity toward the director of SHPDA (State Health Planning and Development Agency), people on the panels, and Hawai’i Health Systems Corporation, which is perceived as the primary obstructionist, was palpably frightening. What next? Apparently further steps are in the works, but the underlying cause of the mess is the absurd health planning law which does not exist in many states. In Ohio and Illinois similar statutes have resulted in bribery with criminal prosecutions. For valid reasons, both the AMA and HMA have policy opposing state health planning laws, but don’t expect it to disappear. It is far easier to eradicate Mt. Rushmore than a government bureau. SHPDA lives on!

YOUTH IS LIKE SPRING; TRANSIENT, EXAGGERATED, AND WITH THE ATTENTION SPAN OF LINT.

We all knew it was coming, and now the hearing loss in young adults has arrived. At the University of California Irvine Medical Center, the effects of the MP3 player which comes with stock "ear buds" has apparently caused damaged hearing in several students. Normally this type of loss would not be seen until 50 or 60 years of age. The sound is digital and kids can crank up the volume without the distortion of previous technologies. Unlike the previous portable headset music players, the MP3 has buds which close off the ear canal and do not allow sound to escape.

HEY! HAS ANYBODY SEEN MY BAYONET?

In the realm of unbelievable medical errors, a Seattle man had abdominal surgery for a tumor. For two months after surgery he complained of pain, but apparently no further studies were performed. When he failed to clear an airport metal detector, x-ray revealed a thirteen (!) inch blade in his abdomen. He won $105,000 in a court settlement; a fair payday for intermittent pain. His attorney said, "It was like missing a truck parked in your front yard."

MONEY CAN BE LOST IN MORE WAYS THAN WON.

According to the Super Bowl Predictor of investments, 2007 is expected to see a rise in stocks. Yes, this completely unscientific indicator has been accurate in 80% (32 of 40) bowls. The factor is whenever an "original" National Football League team wins the big game, e.g. San Francisco, Chicago, Green Bay, the Dow Jones Industrial Average goes up for that year. The market falls when the team is a later addition to the league, e.g New England, Denver. Since both teams, Indianapolis (nee Baltimore) Colts and Chicago Bears are original franchises, your blue chip investments are given a four out of five prediction to rise. Sleep well on your blue chips.

ADDENDA –

----- Fish ‘n Flush is a toilet which doubles as an aquarium. (I did not make this up!)
----- Headline in the Salt Lake Tribune, "Utah risks loosing its best teachers." I think this warning is a bit tardy.
----- Wine is mentioned in every book of the bible except Jonah.
----- What’s medically good for you depends on who sponsors the study.

Aloha, and keep the faith. ----------rts

Contents of this Newsletter do not necessarily reflect the opinion, policy or position of the Hawaii Ophthalmology Society or the Hawaii Medical Association. Editorial comment is strictly that of the writer.
 

ALL GREAT SUCCESS IS A WORK OF ART!

Now there truly is a therapeutic tool for treating macular degeneration (AMD). At a medical meeting in Montreal in July 2005, Genentech Inc. reported the results of a big phase III study which showed that Lucentis when injected into the eye was found to halt blindness in 90% of patients with AMD and improved vision in 30%. This is not just great; it is miraculous! However the cost is $2000 per injection and a two year program would reach nearly $50,000. But wait! Almost simultaneously, additional off-line trials with the anti-cancer compound Avastin, the molecule Lucentis was derived from, has been used by some bold doctors. They found it to be just as effective and it costs a mere $40 per injection. For the first time, the National Institutes of Health (NIH) has received federal funds to conduct a head to head study to compare the two biotechnology drugs. Both compounds are marketed by Genentech, but (needless to say) company executives are hoping Avastin will fail. This test sounds simple enough, but pharmaceutical industry moguls are terrified. They see the study as the first step in the government comparing cost vs. effectiveness and refusing to pay for drugs that fail to make the grade. That is exactly what has happened in the United Kingdom.

MAYBE THEY SHOULD BRING BACK CANING.

In a fourteen year study published in the New England Journal of Medicine, medical students who exhibited unprofessional behavior during training were three times more likely than their colleagues to be disciplined by state medical boards. For those whose behavior included poor attendance and irresponsible patient care, the risk was eight times greater than their colleagues. Principal reasons for discipline were alcohol or other drug abuse, appropriating drugs or mis-prescribing, conviction of a crime, negligence, and unprofessional conduct. Spot the troublemakers while in training and maybe they can be made into professionals.

JUST BECAUSE YOU CAN DO IT, DOESN’T MEAN YOU SHOULD.

Whoa! A team of New York doctors claim they are ready to perform the first uterine transplant for the purpose of helping a woman bear a child. The article in the January Obstetrics and Gynecology outlined how the team would transplant a donor uterus, wait three months to insure proper function, then transfer a frozen embryo, and at term expect to deliver a child by cesarean section and remove the uterus. The spokesdoc claims to have successfully performed the procedure on rats, pigs, rabbits and a rhesus monkey. The procedure has produced a major ethical and technical controversy regarding organ transplant and artificial reproduction, as well as rights of the mother, the embryo donor, and the child. There are so many pitfalls, the concept is almost beyond serious contemplation.

THE NURSING BOARD LACKS SEX REPEAL!

The specialty of the house at the Heart Attack Grill in Tempe, Arizona, is a Quadruple Bypass Burger piled high with four ½ pound beef patties, cheddar cheese, lettuce, tomato and special sauce. But the obvious gastronomic insult is not what has the Arizona State Board of Nursing upset. They are angry because the waitresses wear stethoscopes around their necks, white hats with a cross, brief little skirts, fishnet stockings and tight cleavage-baring tops. The nursing Board even got the attorney general’s office to write a letter stating that the wait staff called themselves "nurses" and were misleading the public. The proprietor, "Dr. Jon," has laughed it off, been very grateful for the publicity, and stated that it is a matter of free speech. He says that the waitress title of nurse is a parody and his clientele is well aware that their skills are limited to food service. Moreover, he is no more a doctor than Julius Irving (Dr. J) the retired basketball star. He offered free french fries to the Arizona State Board of Nursing.

THE THOUGHT OF SUICIDE IS A POWERFUL COMFORT TO THE AFFLICTED.

The issue of physician-assisted suicide was regenerated in the current session of the Hawaii Legislature. In 2005 a similar bill was killed after intense testimony. This time the measure was wisely 86ed after one committee hearing. One difference in the current measure is that physicians would be required to provide the patient’s death wish or refer the patient to a doctor who is willing to help him/her die. Repeated polls have shown that about 60% of Americans believe that people suffering with incurable medical conditions have a right to end their own lives. Yes, that is an important social issue. However, the American Medical Association and the Hawaii Medical Association have consistently held that physicians are in the business of preserving life not ending it, and if society decides to help people die, do not make doctors the hammer.

HIS CAPACITY FOR MENDACITY EXCEEDED HIS VERACITY.

In Florida, a cardio-vascular surgeon testifying on behalf of a plaintiff claimed that he was the lead surgeon in an average of 10 to 12 coronary bypass graft procedures per year in the six years leading up to the case. In fact, hospital records revealed that he hadn’t done any! Now the doctor is facing criminal prosecution for lying under oath about his qualifications and leading the judicial process astray. The case brings to light legislation previously proposed by the Florida Medical Association(and other states) to define the provision of expert witness testimony as the practice of medicine and subject to peer review, but that was defeated by the trial lawyers association. They claim that the judicial system is a good gatekeeper. Ralph Nader and associates often disparage medical societies and state boards for failure to weed out bad docs, but those attempts are inevitably hamstrung by Ralphie’s colleagues.

IS MEDICINE BECOMING A PROFESSION OF QUITTERS?

According to an alarming survey conducted by the American College of Physician Executives, the practice of medicine has become so stressful that 60% of physicians have considered leaving the field. More than one-third have actually sought jobs outside of healthcare. The single largest cause of dissatisfaction was low reimbursement at 22%, followed by loss of autonomy 21%, red tape 17%, job overload and loss of respect 12%, and malpractice environment 11%.

NICE WORK IF YOU CAN GET IT, AND YOU CAN GET IT IF YOU’RE IN THE BIG APPLE AND RICH.

The Transportation Security Administration (TSA) will spend over a half million of your dollars to install a security screening point at a Wall Street location heli-pad. For $139, corporate travelers can fly by a private chopper shuttle service direct to JFK airport, skip security and go undisturbed to the gate. Try to appear appropriately humble.

EITHER WAY, THIS ADDITION BECOMES A DEDUCTION.

In Germany a new statute provides incentive for child-bearing with bonuses up to $33,000. The new year saw a birth boom in January as mothers struggled to hold off delivering in December until the new law kicked in January 1st. Meanwhile, in the United States an estimated 6% of January deliveries were scheduled for labor induction in late December to obtain the $4,000 dependent tax deduction. Either way you get some pay.

ADDENDA –

----- 32% of people carry their Social Security card in their wallet or purse.
----- The eye of the right whale is about the size of an orange.
----- In Atlanta, state officials canceled a severe weather drill because of bad weather.
----- Omphaloskepsis is a form of meditation by means of contemplating one’s navel.
------Flabbergasted is being appalled at how much weight you have gained..

Aloha, and keep the faith. ----------rts

Contents of this Newsletter do not necessarily reflect the opinion, policy or position of the Hawaii Ophthalmology Society or the Hawaii Medical Association. Editorial comment is strictly that of the writer.