Friday, September 30, 2011

Serco: Protocol, Lessons & Medical Training

Every time there is a medical disaster, the management will try and bring 
in a new protocol in the belief that it will be enough to avert criticism. 
But wait: We as doctors already have our protocol and it is called medical training.

The one condition that most of us remembered as an emergency is acute appendicitis and even our Bare Foot Doctors knew about those.

One could hardly believe that a father was asked to be the Bare Foot Doctor!!!

The father of a six-year-old boy who died as a result of a burst appendix was asked to examine him in a Cornish hospital car park, an inquest was told.
Ethan Kerrigan's father Lee had taken him to Penrice Hospital's out-of-hours clinic in June last year after his son had been vomiting for several days.

So he was taken to A & E but why was Serco OOH involved?

In the early hours of 15 June, his father took him to Penrice Hospital in St Austell.
When he arrived he was told to phone out-of-hours service Serco, which he did from the hospital's car park, the inquest heard.

Could this be why? From an earlier blog:

It is not difficult over the New Year period for anyone in the NHS to see how the internal market has continued to fragment our health service.

Look at major hospitals in England: Urgent Care Centres are set up and staffed by nurse practitioner, emergency nurse practitioners and GPs so that the charge by the Hospital Trusts (soon to be Foundation Trusts)  for some people who tried to attend A & E could be avoided. It is often a time wasting exercise and many patients still need to be referred to the “real” A & E thus wasting much valuable time for the critically ill patients and provided fodder for the tabloid press. And payment still had to be made. Currently it is around £77.00 a go. But wait for this, over the New Year some of these Centres would employ off duty A & E Juniors to work there to save some money that Trusts could have charged.

Triage: I now cringe when I hear the term:
On the phone, a triage nurse asked him (father )to examine Ethan's abdomen.

Mr Kerrigan and Ethan's mother, Theresa Commons, both told the inquest that the nurse had asked them to give him ibuprofen, a hot water bottle and make an appointment to see a GP the next day, saying there was nothing to worry about.
The next day, Ethan collapsed in the doctors' surgery in Roche and died later at the Royal Cornwall Hospital, near Truro, from acute gangrenous appendicitis.

It is such a tragic story and it happened in England!

In a statement, Serco said that the death was "a terrible tragedy".
It said: "Serco is committed to providing the highest quality of service to the NHS and the people of Cornwall and the Isles of Scilly, and like any responsible healthcare provider, we seek continuously to learn lessons and to improve how we work.

"Since then we have worked with the local NHS to develop enhanced protocols for handling illness in young children, and these have now been in place for some time".

But wait: this would be the very first clinical lesson from any decent medical school. Why is Serco allowed to continue?

But something is not making sense: in an NHS hospital when this happens, heads roll, but this is Serco and this was reported:

"Serco, which receives over 90% of its business from the public sector, paid Christopher Hyman an estimated £3,149,950 in 2010. This is six times more than the highest paid UK public servant and 11 times more than the highest-paid UK local authority CEO."                       The Guardian

No sign of any resignation!!!

Remember: The best money is Government money, our money. Cherie Blair knows too.

“The medical profession has not been allowed to do its job. The government has forced doctors to implement focus group predicated health care. Professional judgment is neither respected nor required. Doctors' morale is at an all time low. Medical care is now all protocols and process. Protocol driven medical care can be done by monkeys, and often is.”            NHS Blog Doctor.

Protocol unfortunately is there to protect the Serco staff and in turn Serco itself. It really has little to do with actual patient care!!!

Has Serco got a good record of providing GP services?

No. The company runs an out-of-hours GP service (OOH) in Cornwall. It won the contract in April 2006, undercutting local GPs by reducing staff, clinics and  cars. Since then, many people have had problems seeing a doctor in the  evenings and at weekends, and Cornish MPs have warned that patients’ lives  are being “put at risk”. Serco missed almost all of its targets, including emergencies and urgent home visits. Only 55% of emergencies received a visit within one hour in the peak holiday month of August 2006, and the service regularly failed to hit the 100% target for non-urgent cases that should be attended within 6 hours. It was even forced to fly in doctors from Eastern Europe because of a shortage of local GPs willing to work for the company.

One GP who resigned said that during a busy shift a non-medical supervisor “insisted” they leave a patient who was in a “potentially life-threatening situation” to go to the next appointment.

How many deaths will it take till he knows

That too many people have died?

Brain: Then & Now

A common happening in China today:

© 2005 Am Ang Zhang

As the cock crowed, the grandfather left the house on his half mile walk to the little park by the river for his morning Tai Chi with a group of seniors. He was in fact the leader of the group and it fell upon him, a young looking 83 year old to go through the sequence of Tai Chi moves that had been passed down by his grandfather and others before him. His wife sometimes accompanied him but today she had to baby sit the grand-children as their parents were on an early shift. When they finished they sat around for some social chat and drank green tea from their thermal flasks. He walked home refreshed from the morning’s exercise and social gossips. As he neared home he could hear his grand-daughter practicing the piano. What lovely Mozart! He stepped into the house to find his grandson busy at a Nintendo game.

“Why aren’t you practicing your violin? If you just play computer games, your brain will turn into water.”

His grandson shut down the Nintendo, “Grandma, you should try it some time. It will be good for your brain.”

“I am too old for it. My brain is all water anyway, according to grandpa!” She just remembered that she had to take her Ginkgo capsules.

The grandson played some scales on the violin and then the Vivaldi A minor. From memory, as that was how he was trained.

At breakfast, the young children listened to Grandpa reciting ancient classical Chinese poems - a long standing family tradition. Soon the grand-children left for school.

Grandma now cracked some walnuts while grandpa got ready to go to the market to see what fresh fish he could buy that day. The walnut was to go with their home reared free range chicken. They grew their own vegetables too.

Later that day they would be having a good game of Mahjong with a retired couple.

Much of what they did would help to maintain their brain fitness.

The grandfather’s comment on computer game and grandma’s consumption of Ginkgo were “give-aways” that they had not read the new book after all. Ginkgo biloba with its romantic botanical history is no longer the Dementia buster it promised to be. (Those who know of the village in Japan where there are loads of Ginkgo trees could have told you that. The village has the highest Alzheimer rates in Japan.)

I was reminded of Woody Allen’s film, Radio Days, where the young Allen (who else) was brought before the Rabbi by his mother for his advice because Allen was hooked onto the radio. The Rabbi’s skepticism was perhaps not that dissimilar to ours nowadays about iPhones, computer games and brain exercises. Indeed the young Allen should be concentrating on his upcoming Bar Mitzvah and the Torah memorizing.

The Old views on Brain.

When I was training in London in the 70s, I spent some time at Queen Square. Those in the know will recognize it as the place for neurology this side of the Atlantic. It was drilled into us then that sadly we were given a number of brain cells when we were born and it was all downhill from then on or something to that effect. It was well known that neurologists were great diagnosticians but for most neurological conditions, not much could be done. How depressing indeed. Even as recently as four weeks ago, I heard a young doctor told his father that there was nothing he could do with his brain cells. One is given so many at birth and no more can be expected. Lord Brain (1895-1966) would have been so proud.

Yet it was also London that shook the world with new discoveries about the brain, and the study was on the most unlikely group of people: Taxi drivers. Their “KNOWLEDGE” was the basis of our knowledge on brain plasticity today. The “KNOWLEDGE” is a term officially used to describe the test the Taxi Drivers had to take to get the licence to drive Taxis in London. Streets in Londonhave evolved over time and are not on any grid system at all. Early postmortem examinations led some pathologists to note the small size of the Taxi drivers’ frontal lobes. Yet actual weight measurement showed that size was all relative. It was the enlarged hippocampal region that created that impression. Later work using modern scanning techniques confirmed the early impressions.

If two to four years of “KNOWLEDGE” acquisition can change the size of the brain in a grown adult, what else could we do?

The rest, as they say, is history.

The SharpBrains Guide To Brain Fitness 
I have been a regular visitor to the SharpBrain blog and have enjoyed the musings and scientific material presented on the site. When Mr. Fernandez offered the newly published book: The SharpBrains Guide to Brain Fitness for review, I jumped at the chance.

Yes, London Taxi driver is mentioned in the book, and so I thought that is a good sign.

The book also covers the changes to the brains of musicians and medical students. It tells us that just three months of memory work can have noticeable effect on the brain of medical students, and music memory work has similar impact on musicians. I was pleased to learn that Bilingualism helps too. From infancy, I and my siblings were brought up with speaking two Chinese dialects at home.

Will medical schools that have abandoned traditional teachings please bring back Anatomy-the old way?

Did the 300,000 or so that took up piano this year in China know a thing or two about brain plasticity? Currently 30 million children are reported to be learning the piano in China.

The skeptics would see the primary purpose of “The Sharpbrains guide to Brain Fitness” as the promotion of some computer training software. There is no obvious conflict of interest I could detect and the book is a convenient place to look at various software under one roof so to speak. The interviews are interesting but nearly all interviewees have some vested interest in some software. As a child psychiatrist, I find the ones on ADHD showed great promise but I doubt if we are ever going to see the end of the stimulants’ hold on the condition in the West. It is interesting to note that Stimulants never took off in China, a country with a fifth of the world’s population. Computer games, on the other hand, have really taken off there.

The book is easy to read, and has a clear structure, although I found it difficult to look for specific references. Later I discovered that these are to be found on their website.

Bridge and Sudoku were mentioned in passing, along with other favourites like crosswords. There is no mention of Mahjong although in the East it is all the rage, nor the memory work required in some religions. Their gods might know a thing or two about the brain.


Other Posts:

Nobel: Kandel and Lohengrin

Lohengrin: Speech Disability, Design & Hypertension

Autism, the Brain and Tiger Woods

'The Knowledge' and the Brain

Wednesday, September 28, 2011

Andrew Lansley: Genius & Fraud

It is interesting to come back to somewhere where I can start catching Cockroaches.

Before then, I realised what a genius our Health Secretary really is:

The Guardian: Lansley's claims about hospital PFI debt 'misleading'!
He has managed to turn so many to now love PFI. Wow!
But wait: he has also set out the justification to sell off the 22 hospitals to the likes of Circle or Netcare. Win! Win!

But is the genius ready to deal with Medical Fraud?

Baltimore Sun:
September 17, 2011

Something didn't look right. Maxim Healthcare nurses were showing up at Richard West's house according to one schedule. But Maxim was billing the government according to another.

West complained to the state: The company was charging for hundreds of hours of work it never did. Officials blew him off, he said. He alerted Medicaid, the state and federal program that paid for his care. Nothing happened.
He told a social worker. She expressed concern, but did nothing. But West, a Vietnam vet with muscular dystrophy, kept pushing and pushing, building a giant, accusatory snowball that landed last week — eight years later — on Maxim's Columbia headquarters.

Maxim has signed a criminal and civil settlement related to allegations that it schemed to rip off $61 million from state and federal governments, law enforcement authorities said last week. The company is paying $150 million in penalties and recompense. Eight former Maxim employees so far have pleaded guilty to felony charges in several states.

If Washington is as serious about fighting medical fraud as it pretends to be, it will recruit an army of Richard Wests to burn off leeches like Maxim. Nobody is in a better position to see fraud than patients, who can check the care they receive against what's on the invoice.

Now that West has shown that patients can get rich in the bargain, there's plenty of incentive. Not that his motivation was his $14.8 million share of the settlement. Anger was. He didn't even know about such whistleblower rewards at first.

"Somebody decided to make a profit on my disability," West said in a telephone interview. "This is your country. You see fraud, you should turn them in. That is part of being an American."

Whistleblower rewards under the federal False Claims Act have been around since the Civil War. The recent caseload has been dominated by allegations of Medicare and Medicaid fraud, which costs taxpayers billions of dollars a year.

In almost every instance, the person who alerts law enforcement is a corporate insider, not a patient. West's information in the Maxim case was so compelling, however, that the government credited him as the "original source," with independent and direct knowledge of the fraud.

He kept spreadsheets on the gaping discrepancy between the hours Maxim nurses spent in his home north of Atlantic City, N.J., and the hours Maxim billed Medicaid. Eventually he documented more than 700 hours of bogus charges, according to the New Jersey attorney general.

After a couple months of detective work, West got in touch with Baltimore lawyer Robin Page West (no relation), who specializes in whistleblower lawsuits. Together they built a case, filed it under court seal in 2004 and turned it over to law enforcement. And waited.

West, 63, speaks precisely but with difficulty, in a high-toned voice. He says he commanded an Army track vehicle with 40 mm guns in Vietnam in 1968 and 1969 — the deadliest years of the war there. Yet biding his time while investigators built their file, he said, "was the hardest thing I've ever done."

See also:

Tuesday, September 27, 2011

Children: USA & Cambodia

Over the last ten years or so, I kept meeting friends in the U.S. whose children seemed to progress from one psychiatric diagnosis to another with frightening regularity, the most common being from ADHD to Bipolar. One grandmother recently asked me what I thought of Bipolar illness in children.

“Well my grandson of five has just been diagnosed. To me he is just an imaginative bright young thing and I never really had any problems with him when he spent part of the school holidays with me. But now he is on all these medications……” she told me.

Her own husband is a physician and her son is a dentist.

In the New York Times, the headline reads:
Child’s Ordeal Shows Risks of Psychosis Drugs for Young

Chris Bickford September 1, 2010

At 18 months, Kyle Warren started taking a daily antipsychotic drug on the orders of a pediatrician trying to quell the boy’s severe temper tantrums.

Thus began a troubled toddler’s journey from one doctor to another, from one diagnosis to another, involving even more drugs. 


Autism, bipolar disorder, hyperactivity, insomnia, oppositional defiant disorder.

The boy’s daily pill regimen multiplied: the antipsychotic Risperdal, the antidepressant Prozac, two sleeping medicines and one for attention-deficit disorder. All by the time he was 3.

He was sedated, drooling and overweight from the side effects of the antipsychotic medicine. ……Mother: “I didn’t have my son. It’s like, you’d look into his eyes and you would just see just blankness.”

A Columbia University study recently found a doubling of the rate of prescribing antipsychotic drugs for privately insured 2- to 5-year-olds from 2000 to 2007. Only 40 percent of them had received a proper mental health assessment, violating practice standards from the American Academy of Child and Adolescent Psychiatry.

No risk of medication for the Cambodian children© 2009 Am Ang Zhang
From my previous post:

“A world-renowned Harvard child psychiatrist whose work has helped fuel an explosion in the use of powerful antipsychotic medicines in children earned at least $1.6 million in consulting fees from drug makers from 2000 to 2007 but for years did not report much of this income to university officials, according to information given Congressional investigators.”

Who is the psychiatrist?

“By failing to report income, the psychiatrist, Dr. Joseph Biederman, and a colleague in the psychiatry department at Harvard Medical School, Dr. Timothy E. Wilens, may have violated federal and university research rules designed to police potential conflicts of interest, according to Senator Charles E. Grassley, Republican of Iowa. Some of their research is financed by government grants.”

It was Dr Biederman’s presentation I heard at the conference I mentioned earlier. This is interesting!

“Like Dr. Biederman, Dr. Wilens belatedly reported earning at least $1.6 million from 2000 to 2007, and another Harvard colleague, Dr. Thomas Spencer, reported earning at least $1 million after being pressed by Mr. Grassley’s investigators.”
The New York Times was quick to point out that these figures were most likely an under-estimate.
“Dr. Biederman is one of the most influential researchers in child psychiatry and is widely admired for focusing the field’s attention on its most troubled young patients. Although many of his studies are small and often financed by drug makers, his work helped to fuel a controversial 40-fold increase from 1994 to 2003 in the diagnosis of paediatric bipolar disorder, which is characterized by severe mood swings, and a rapid rise in the use of antipsychotic medicines in children. The Grassley investigation did not address research quality…..

In the past decade, Dr. Biederman and his colleagues have promoted the aggressive diagnosis and drug treatment of childhood bipolar disorder, a mood problem once thought confined to adults. They have maintained that the disorder was under-diagnosed in children and could be treated with antipsychotic drugs, medications invented to treat schizophrenia….

Doctors have known for years that antipsychotic drugs, sometimes called major tranquilizers, can quickly subdue children. But youngsters appear to be especially susceptible to the weight gain and metabolic problems caused by the drugs, and it is far from clear that the medications improve children’s lives over time, experts say.
What is the number of children involved?

“Some 500,000 children and teenagers were given at least one prescription for an antipsychotic in 2007, including 20,500 under 6 years of age, according to Medco Health Solutions, a pharmacy benefit manager.” 

This is why I have always argued that reports from parents, teachers and children cannot entirely replace direct clinical observation.

“More broadly, they said, revelations of undisclosed payments from drug makers to leading researchers are especially damaging for psychiatry.”

Money corrupts.

Bipolar Disorder in Children: USA

A reprint: 

Prediction is often the domain of Quantum Physics and the most spectacular prediction of all time has to be Einstein’s theory of General Relativity regarding gravity and light. The 1919 eclipse on May 29 proved his theory and made Einstein famous overnight. 

Historic picture Royal Observatory Greenwich

To quote the NASA site: "extraordinary claims require extraordinary evidence"!

It was unusual to find prediction being used in modern medicine let alone Child Psychiatry.

San Francisco Chronicle 
March 27,2009
“Dr Biederman appears to be promising drugmaker Johnson & Johnson in advance that his studies on the antipsychotic drug risperidone will prove the drug to be effective when used on preschool age children.”
And we do not have to wait for an eclipse. Wow! I have to declare that I have heard him at a conference and I reported this in a previous blog: Bipolar and ADHD: Boys and Breasts.

The San Francisco Chronicle article continues:

“Biederman's status at Harvard and his research have arguably made him, until recently, America's most powerful doctor in child psychiatry. Biederman has strongly pushed treating children's mental illnesses with powerful antipsychotic medicines. Diagnoses like ADHD and pediatric bipolar disorder, along with psychiatric drug use in American children, have soared in the last 15 years. No other country medicates children as frequently.”

No other country medicates children as frequently!
“Reports from court actions, along with an ongoing investigation of conflict of interest charges led by Sen. Chuck Grassley, R-Iowa, threaten to topple Biederman from his heretofore untouchable Olympian heights. Biederman has cried foul.”

“He says the drug company dollars (declared and undeclared) have not influenced him or his research. He had agreed temporarily to sever most of his financial ties with the drug industry pending the outcome of the ongoing inquiry.

“He claims his science and publications are pure, supported by a peer-review system that is supposed to verify accuracy and authenticity. Finally, he challenges as office gossip reports of his legendary anger and intolerance of those who disagree or don't support his proposals.”

The New York Times:

"In a contentious Feb. 26 deposition between Dr. Biederman and lawyers for the states, he was asked what rank he held at Harvard. 

“Full professor,” he answered.
“What’s after that?” asked a lawyer, Fletch Trammell.
“God,” Dr. Biederman responded.
“Did you say God?” Mr. Trammell asked.
“Yeah,” Dr. Biederman said.

Latest: 3 Researchers at Harvard Are Named in Subpoena

Related Posts:
Lithium Bipolar and Nanking
Bipolar Disorder in Children
Bipolar and ADHD: Boys and Breasts
Bipolar Disorder: Biederman Einstein God.
Antipsychotics: Really?
Bipolar and ADHD: Boys and Breasts
Grand Round: Medicine and War
Bipolar Disorder: Lithium-The Aspirin of Psychiatry?

Monday, September 26, 2011

Medicine: Real or Rare Conditions

I have often wondered if the government is right after all: most of the time we do not need doctors.

What is the point of spending years studying about some fairly rare conditions and then when the time comes we still miss it. This was covered in the recent uproar about the boy with Addison’s disease by Dr Crippen and Jobbing Doctor. Then we have the X-Factor boy with a 2 Kilogram tumour that remained undiagnosed till late.

I remembered graduating from medical school quite worried about treating patients as we seemed to know all the rare conditions but little about coughs and colds.

We all know about Hodgkin, Von Recklinghausen and Rett.

Have they done such a good job dumbing down the new generation of doctors or were they too busy with Hemlock to have time for much else? 

Even in the US were they too busy working for the big drug firms to have time to teach them real medicine?! Has everything got to be ADHD, Bipolar or psychosis. Especially ADHD for a 39 year old?!

In this week’s Sunday New York Times: 

March 15, 2009
“She was 39. Divorced. Lived alone. She took two medications for high blood pressure, as well as an antidepressant and a stimulant, Concerta, a long-acting form of Ritalin, for a diagnosis of attention-deficit disorder.”
Psychosis and mania were rare but documented side effects of Concerta. Was that the cause of her symptoms or was this simply a manic episode in an underlying bipolar disorder?”

A mysterious psychosis!

The consultant stopped the stimulant and tried to start the patient on antipsychotic and mood-stabilizing medications.

“She refused to take them, so he gave the medication by injection. Slowly her behavior began to change. The wild swings of emotion and outbursts of anger became less frequent. But strangely, her disordered thinking and paranoid delusions persisted. Usually these symptoms improved and worsened together.”
The psychiatrist was called because the nurse could not get her blood pressure.
No, she was not in shock. It was so high it went off the scale.

The Internist was called and she got a high reading of 240/110 and the patient was put into ICU.

I hope by now you have guessed what the diagnosis was.

PHEOCHROMOCYTOMA: the one we all know about. Used to!

But why should the patient not have pheochromocytoma and ADHD and paranoid psychosis and a touch of bipolar. She was after all suicidal and she thought the police came after her seven times!

Perhaps the psychiatrist was still brought up on ONE PATIENT ONE DISEASE.

The Sunday paper continued:

“The psychiatrist had taken her off Concerta, the stimulant, because he knew that it sometimes causes psychosis and mania. That drug works, in part, by causing an overproduction of adrenaline.
“If the drug could sometimes cause psychosis and mania, could this adrenaline-producing tumor do the same thing? He found several papers describing patients who, like this woman, had pheochromocytomas as well as mania and psychosis. The symptoms resolved once the tumor was removed. It was unusual, but it had been reported.”
“And finally, after a year and a half, she was medication free and remains so to this day, three years after her surgery.”

You can read the full story here. New York Times, Lisa Saunders, M. D.

Pheochromocytoma: One Patient One Disease.

Narrowing of the renal artery.

Top: CNRI/Photo Researcher
Bottom: ISM/Phototake.