Medicine News: mayo 2015

domingo, 31 de mayo de 2015

Preserving patient autonomy is the ultimate respect

There is much to learn as a new physician, but some patients teach you things you never meant to learn. This happened to me a few months ago. I was taking care of a 26 year old who had an end-stage, inoperable brain tumor that was causing progressive seizure activity. He was admitted with a […]

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LITFL Review 184

Welcome to the 184th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

resizer Here’s an awesome new echo resource from the Nepean Hospital ICU in Penrith, NSW, Australia, containing basic and advanced physics and scanning resources. [SO]

The Best of #FOAMed Emergency Medicine

Boring EM reviews the relevance of INR measurements to risk of bleeding during a procedure in patients with liver disease. [AS]
It’s not just about video versus direct laryngoscopy. It’s about the angulation of the blade. Great slidecast from Reuben Strayer. [AS]

The Best of #FOAMcc Critical Care

Rory Spiegel reviews the recent NEJM article on high-flow nasal canula (HFNC) over non-invasive ventilation or standard oxygen therapy in non-hypercarbic, hypoxemic respiratory failure. Although this article doesn’t provide definitive proof of benefit, Rory discusses how the information can guide clinical care. [AS]
The Bottom Line has a nice complimentary review to Rory’s post on high-flow nasal canula with some additional critiques and thoughts. [AS]
As if the top two weren’t enough, both Justin Mandeville (ICMWK) and Josh Farkas (Pulmcrit) have further discussions around this trial. Check out Justin’s review here and Josh’s here. Is it time to buy shares in HFNC? [SO]
Concerned about giving peripheral vasopressors prior to central access? Check out
this post from Rebel EM. [SL]

The Best of #FOAMus Ultrasound

Emergency Medicine Cases has a journal jam pitting ultrasound against CT for renal colic. [MG]

The Best of #FOAMim Internal Medicine

In this first of University of Louville’s two-part series on spondylarthropathies, rheumatologist Dr. Charles Moore discusses a clinical approach to patients with ankylosing spondylitis, polymyositis/dermatomyositis, inclusion body myositis, anti-synthetase syndrome and scleroderma. [ML]

The Best of Medical Education and Social Media

EM Mindset from Matt Dawson – Compassion, Humility, Curiosity, Humor, Courage. [AS]

News from the Fast Lane

The SMACC 2015 Schedule for the June 23-26th conference in Chicago is online [AS]
Check out another jammed packed edition of Research and Review in the Fast Lane 085 [ML]

Reference Sources and Reading List

Emergency Medicine and Critical Care blog/podcast list
LITFL Global Blogroll
FOAMEM RSS feed syndication for global FOAM
Twitter: #FOAMed – #FOAMcc – #FOAMtox – #FOAMped – #FOAMus – #FOAMim

Brought to you by:

Anand Swaminathan [AS] (EM Lyceum, iTeachEM)
Brent Thoma [BT] (BoringEM and Academic Life in EM)
Chris Connolly [CC]
Chris Nickson [CN] ( iTeachEM, RAGE, INTENSIVE and SMACC)
Joe-Anthony Rotella [JAR]
Kane Guthrie [KG]
Mat Goebel [MG]
Segun Olusanya [SO] (JICSCast)
Simon Laing [SL] (HEFTEMCast)
Tessa Davis [TRD] (Don’t Forget The Bubbles)
Marjorie Lazoff [ML]

The post LITFL Review 184 appeared first on LITFL: Life in the Fast Lane Medical Blog.

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The challenge of evidence-based medicine to the new physician

Evidence-based medicine (EBM) has been classically described as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” At first look, this well-accepted approach to clinical medicine appears not only completely reasonable, but also somewhat obvious given the immense amount of research available for academic consumption. […]

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A neurosurgeon teaches us about degenerative disc disease

No one wants to hear that they have a disease. And yet everyone will develop some degree of degenerative disc disease (DDD) — or degenerative spine disease — over the course of a lifetime. DDD refers to a combination of age-related and wear-and-tear-related changes that occur within the spine over time. It is very common […]

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What is a stroke and what are its symptoms? These doctors sketch it out.

A new series by the physicians over at Health Sketch explain what a stroke is and its symptoms. A nice explanation, presented in visual, easy to understand terms. Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.

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After third year: What a medical student wishes he did differently

With my third year of medical school coming to a close, here is what I wish I did differently, wish I knew beforehand or figured out along the way during my core clinical rotations. It’s nothing groundbreaking, and you may have heard this before, but it can’t hurt to hear it from someone else. Continue […]

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Doctors and nurses vs. administrators on patient satisfaction. Who’s right?

I’ve been volunteering in an emergency department of a Southern Californian community hospital for five years. I clean gurneys, stock shelves, provide support for RNs and EMTs and translate for Spanish-speaking patients. Since my job requires minimal intellectual effort, I’ve had considerable time to observe the staff and contemplate the inspiring work they do. I’ve […]

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Our feedback model is broken. Here’s how to change it.

I recently gave two talks at my residency program, one on health care innovation and another on intimate partner violence. I know little about each topic, but my goal as presenter was merely to know more than each person in the room. To require residents to give talks as newly-minted “experts” on topics creates a […]

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MKSAP: 53-year-old woman with swelling of the face, hands, and feet

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 53-year-old woman is evaluated for a 3-month history of swelling of the face, hands, and feet. She has untreated hepatitis C virus infection. She takes lithium for bipolar disorder. She has no additional symptoms. On physical examination, temperature is normal, […]

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JellyBean 024 with Damien Roland

Damien Roland has been at the centre of an interesting grass-roots, bottom up movement in the UK all based around the idea that everyone can make a change.The National Health Service is the 4th biggest employer in the world. Set up after second World War by Aneurin Bevan based on the 1942 Beveridge report and a movement that had started back before first World War.

Its been under the cosh for the last few decades as successive governments of every persuasion have tried to cut its funding, privatize its profitable components and downsize it in any way possible. The NHS is expensive, it is inefficient, it makes mistakes. It is, in many ways, the best health service in the world.

It is big. As with a lot of big things those involved can feel very removed from the exercise of power. Nurses, doctors, patients can all feel like it’s impossible to get the damn thing to change. It’s all committees, reports, bureaucracy, politics, back-stabbing…. You know…the sort of stuff any big corporation or organization has.

The politicians that are making the laws at the moment are among the tiny proportion of Britons that can afford and use private healthcare. But people love the NHS. It still has the trust and appreciation of (most of) the millions that depend upon it as their only source of healthcare.

That’s a lot of untapped good will from a lot of untapped minds. Imagine more than half a million people (and counting) trying to dream up little (or big) things to improve the healthcare experience. We all go through this experience, some of as staff and almost all of us as patients.

It’s an interesting “Soft-Power” phenomenon. Have a wee look at NHS Change Day

The post JellyBean 024 with Damien Roland appeared first on LITFL: Life in the Fast Lane Medical Blog.

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3 ways doctors can use social media today

A continuing series on physician online reputation. Created in partnership with The Doctors Company as part of their social media resources for physicians. Let’s talk about three ways that physicians can use social media today. The first way is to filter information. More patients than ever are going online to research their diagnosis and treatment options […]

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Physician, heal thyself. But is it even possible today?

Physician, heal thyself. That’s the unwritten rule, sadly, for us. I am a physician. I am therefore invincible and inhuman and all the things my patients cannot be. To seek help is a sign of weakness, and our profession has no place for the weak of body, mind or spirit. We work through illness because […]

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Team-based training is key to providing team-based care

One of the core components in transforming a practice is team-based care, and this concept consistently is a focus of many conversations among physicians across the country. My employer, the Quillen College of Medicine at East Tennessee State University (ETSU), also has embraced this concept. And the outstanding group of interprofessional educators with whom I […]

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No, doctors don’t need resiliency training. Here’s why.

Here’s the latest medical fad: Physician resiliency training. Huh? Doctors are already the most resilient people on the planet. Doctors can go days on call without eating. I know. I have. Doctors can go 24 hours without a bathroom break. (Yes, we even have the most resilient bladders!) Continue reading ... Your patients are rating […]

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What items are on your EHR wish list? Here’s mine.

A guest column by the American College of Physicians, exclusive to KevinMD.com. Last month, I shared my take on the mess that we find ourselves in with our electronic health records (EHRs) and referred to the recently published ACP position paper on clinical documentation. The paper includes a list of recommendations for EHR system design. These are […]

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Why medical students need to take care of themselves during training

When I began volunteering during my first year of medical school at our student-run free clinic, I noticed that I felt stressed out in the chaotic environment, from the director’s tough questions and the long wait times to present to an attending. My muscles tight, I would feel exhausted after leaving the clinic. I knew, […]

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When young patients become pregnant before they are ready to be parents

As adolescent medicine physicians based in the Bronx, which has one of the highest teen pregnancy rates in the nation, we frequently see how young patients become pregnant before they are ready to be parents. Continue reading ... Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. […]

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We’re losing the war on error. And here’s why.

The war on medical error was officially launched in 1999, when the Institute of Medicine (IOM) published its landmark report To Err is Human, alleging that up to 98,000 yearly deaths in US hospitals were due to human missteps. Continue reading ... Your patients are rating you online: How to respond. Manage your online reputation: […]

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What Ezekiel Emanuel gets wrong about physician salaries

I’m usually a huge fan of Dr. Ezekiel J. Emanuel’s writing — whether it’s his controversial piece on health care resources at the end of life or his book describing the tumultuous health care policy that led up to the Affordable Care Act, I generally enjoy reading his editorials and vehemently agree with many of his opinions. This being said, when I […]

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This is what it’s like to be a patient. Doctors need to see this.

Ever wonder what patients think of when you see them in the hospital? Here’s the answer, in this powerful video from the Cleveland Clinic. Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.

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Should I go into radiology? A radiologist gives honest answers.

I used to be a surgical resident in the U.K. One day, I was a little dispirited during a brutal call, and my senior resident asked, “Do you love surgery?” “I like surgery,” I replied. “If you don’t love surgery, love it unconditionally I mean — like loving your child — you will be unhappy.” […]

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What’s meaningful to the government may not be to patients

The whole thing was rather awkward. I have to admit that I was nervous. I perused the records before he walked through the exam room door. These conversations were always difficult and felt out of place in the office. But I had looked at the numbers over and over again. There was a glaring deficiency […]

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You’re taking my blood pressure wrong. Listen to this patient.

I went to the doctor yesterday, my semi-annual visit, as it were. These days I see a nurse practitioner, a woman. Recently, she and the practice she is a part of moved into a renovated building, state-of-the-art, they are calling it. It almost sparkles in its newness. The practice is owned by one of the […]

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The problem with cowboy doctors in health care

Some months back I read an interesting interview with Jonathan Skinner, a researcher who works with the group at the renowned Dartmouth Atlas of Health Care. More than anyone else I can think of, the people at the Dartmouth Atlas have studied and tried both to understand and to explain the amazing variations we see […]

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A powerful reminder of medicine’s humbling nature

“A thousand times we die in one life. We crumble, break and tear apart until the layers of illusion are burned away, and all that is left, is the truth of who and what we really are.” The coronary care unit (CCU) rotation is a unique place. Postoperative cardiothoracic surgery patients among many other pathologies […]

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Sucker punched and bleeding. Do you know how you’ll respond?

I just stepped out of the administrative building at medical school and hear a big commotion. I look over and see an elderly male slouched on the ground bleeding profusely from his mouth and nose. Blood is soaking the front of his collared shirt and pooling on the ground. Bystanders are making a scene and not […]

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Doctors need to take care of each other. Starting now.

I like to think that doctors are still a profession made up of people who want to help others. Sure, there are other benefits to our jobs. The technical challenge, the intellectual rewards, the financial security. But honestly, we do really get a lot from helping others. It’s satisfying to look to your fellow man […]

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What Dr. Seuss would think about health care consolidation

Health care consolidation affects every area of health care. What does this radiologist-illustrator think about it? I think it speaks for itself. James Chang is a radiologist and author of Oh Doctor, The Places You Will Go… He blogs at Poor MD and can be reached on Facebook. Your patients are rating you online: How to respond. Manage your […]

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The challenge of evidence-based medicine to the new physician

A neurosurgeon teaches us about degenerative disc disease

We’re losing the war on error. And here’s why.

A neurosurgeon teaches us about degenerative disc disease

What is a stroke and what are its symptoms? These doctors sketch it out.

What Ezekiel Emanuel gets wrong about physician salaries

What is a stroke and what are its symptoms? These doctors sketch it out.

sábado, 30 de mayo de 2015

After third year: What a medical student wishes he did differently

Doctors and nurses vs. administrators on patient satisfaction. Who’s right?

Our feedback model is broken. Here’s how to change it.

MKSAP: 53-year-old woman with swelling of the face, hands, and feet

JellyBean 024 with Damien Roland

It’s an interesting “Soft-Power” phenomenon. Have a wee look at NHS Change Day

The post JellyBean 024 with Damien Roland appeared first on LITFL: Life in the Fast Lane Medical Blog.

via Medicine Joint Channels

3 ways doctors can use social media today

Physician, heal thyself. But is it even possible today?

Team-based training is key to providing team-based care

You’re taking my blood pressure wrong. Listen to this patient.

The problem with cowboy doctors in health care

A powerful reminder of medicine’s humbling nature

Sucker punched and bleeding. Do you know how you’ll respond?

MKSAP: 53-year-old woman with swelling of the face, hands, and feet

JellyBean 024 with Damien Roland

It’s an interesting “Soft-Power” phenomenon. Have a wee look at NHS Change Day

The post JellyBean 024 with Damien Roland appeared first on LITFL: Life in the Fast Lane Medical Blog.

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3 ways doctors can use social media today

The problem with cowboy doctors in health care

viernes, 29 de mayo de 2015

JellyBean 024 with Damien Roland

It’s an interesting “Soft-Power” phenomenon. Have a wee look at NHS Change Day

The post JellyBean 024 with Damien Roland appeared first on LITFL: Life in the Fast Lane Medical Blog.

via Medicine Joint Channels

3 ways doctors can use social media today

Physician, heal thyself. But is it even possible today?

Team-based training is key to providing team-based care

No, doctors don’t need resiliency training. Here’s why.

The problem with cowboy doctors in health care

A powerful reminder of medicine’s humbling nature

Sucker punched and bleeding. Do you know how you’ll respond?

JellyBean 024 with Damien Roland

It’s an interesting “Soft-Power” phenomenon. Have a wee look at NHS Change Day

The post JellyBean 024 with Damien Roland appeared first on LITFL: Life in the Fast Lane Medical Blog.

via Medicine Joint Channels

3 ways doctors can use social media today

Physician, heal thyself. But is it even possible today?

Team-based training is key to providing team-based care

No, doctors don’t need resiliency training. Here’s why.

What items are on your EHR wish list? Here’s mine.

Why medical students need to take care of themselves during training

Chiropractic Nose Balloons

You can pick your friends. You can pick your nose. But you can’t pick your friends nose. Unless you practice Nasal Cranial Release.

There are so many pseudo-medicines, it is hard to keep track. New variations appear, new combinations of old SCAMs occur, old pseudo-medicines wax and wane, although no pseudo-medicine ever dies. Except phenology? Maybe? I find a few phrenology sites on the web, but I cannot tell if they are real or satire.

There is an ongoing discussion in my family as to the greatest band of all time. The Who is THE correct answer, but really, bands do not have to follow the Pauli exclusion principle. There can be multiple greatest bands of all time, all existing simultaneously at the same place. Except that the Who is a little bit more greater than the others. Yes. More greater.

The same concept applies to SCAM’s. Whose goofiness reigns supreme? Homeopathy? Reiki? Epigenetic Birth Control? They are all equally goofy, each in their own special way.

In my feeds I saw the announcement that Anderson Chiropractic Announces Nasal Cranial Release Therapy. I had never heard of Nasal Cranial Release Therapy. It sounds bad, turning humans into a PEZ dispenser, popping off the skull by way of the nose, a particularly horrific form of rhinotillexomania. It’s not that goofy. But close.

Nasal Cranial Release appears to be the mutant offspring of chiropractic and cranio-sacral therapy and goes by a variety of other names including

Endonasal Technique, Bilateral Nasal Specific Technique, Functional Cranial Release, and Neurocranial Release

Balloons, or hobbit condoms, I can’t tell from the photographs, are inserted in the nose and inflated to realign cranial bones. Really. Watch the video. Judging from the patient it is not a pleasant experience. And I always watch these videos with the eye of an infection control doctor. No gloves or hand hygiene to be seen and given the propensity for MRSA to be harbored in the nose it gives me the willies. The proccedure appears to be booger compression, an intervention I suspect no one really needs. Compressing snot is unlikely to have any significant anatomic or physiologic effects.

The method is different than Balloon sinuplasty where the sinuses are opened up by expanding a balloon in the sinus ostia. In contrast to Nasal Cranial Release the balloon is directed into place with a endoscope and look! they use local anesthesia and wear gloves in a procedure room. Watch the videos sequentially and compare and contrast real medicine with cargo cult medicine.

Nasal Cranial Release was developed in the 1930’s by a chiropractor and naturopath in Portland Oregon. to treat concussion and traumatic brain injury. Really. It gives me the heebie-jeebies to think of inflating a balloon in the nose after traumatic brain injury. The balloon should do nothing to normal skulls, but if there were an occult basilar skull fracture?

The information to support the practice is almost, but not quite, entirely unlike data. I found case report that after

Chiropractic manipulation and soft tissue manipulation administered 2–6 times per month for approximately 1 yr had minimal long-term effect on the patient’s head pain.

Really? The patient returned 6 times a month for a year with no effect from the intervention? That’s salesmanship.

Then the patient had resolution of the headache after several months (!) of nasal realignment. The patient probably reporting improvement so they would never have to return for more treatments. It would appear to be the only way to escape the clutches of that particular chiropractor.

Even chiropractors admit that

No articles appear available in the scientific literature that examine the efficacy of the nasal specific technique for treating any pathology. Searching for such literature uncovered one unpublished study by Nyiendo and Goldeen. Their study concluded that claims for improved vision and hearing following nasal specific treatment could neither be supported nor refuted. They did find, however, changes in craniofacial measurements that did not reach significance when compared to a control (sham-treated) group.

No known efficacy and no effect on the skull, yet like all pseudo-medicines, the ‘indications’ are broad. Mostly suggested for concussion and head trauma, it is also suggested for a variety of neurologic diseases and symptoms.

One chiropractic site even suggests it will prevent the need for braces. The mechanism?

the connective tissues that surround your brain and spinal cord called the Dura Mater are specifically released using endonasal balloon inflations.

and the nasal balloons

Restore the brains ability to oxygenate itself through both improving air flow into higher area’s through the nasal passage

Which made me giggle as it seems to imply that oxygen gets to the brain directly across the base of the brain rather than from the arteries by way of the lung.

No surprise, the only reports on Pubmed I could find are complications: fracture and bleeding.

Chiropractors like to brag that their education is on par with MD’s. Then they do bone-headed pseudo-science like this, actually thinking that by inflating a balloon in the nose they can place

… the bones in better alignment allows for optimal blood flow to the brain and spinal cord and neuro-transmitter activity throughout the central nervous system.

After a shorter version of this essay a chiropractor commented

Please don’t generalize. Most chiropractors don’t do this ridiculous crap and we definitely do not learn this in chiropractic school.

As if correcting spinal subluxations, the raison d’être of chiropractic, is any less goofy. And maybe the other ridiculous crap in chiropractic school will be no longer be taught:

European Schools Sign Anti-Subluxation Position Statement

Six chiropractic schools signed a position statement that says

The teaching of vertebral subluxation complex as a vitalistic construct that claims that it is the cause of disease is unsupported by evidence. Its inclusion in a modern chiropractic curriculum in anything other than an historical context is therefore inappropriate and unnecessary.

which is similar to the General Chiropractic Council in the United Kingdom, which has a Guidance that says

The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.

They are referred to “Subluxation Deniers.” Like Vaccine and Global warming deniers, one of these is not like the others.

I wonder if all the ridiculous crap is removed from chiropractic practice, what will be left?

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jueves, 28 de mayo de 2015

Mainstream media can help a physician online reputation

A continuing series on physician online reputation. For more KevinMD minutes, please visit my YouTube channel Did you know that talking to mainstream media is a great way to define your reputation online? That’s because newspaper stories and television appearances eventually will find their way online, and it’s a great way to control the […]

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Is your anesthesiology practice poised for success?

A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com. Earlier this year, I spoke to an audience of physician anesthesiologists about setting up a basic quality assurance (QA) program within their departments. At the end of the presentation, one physician anesthesiologist stated that his group “will not let anyone out of the […]

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When young patients become pregnant before they are ready to be parents

We’re losing the war on error. And here’s why.

What Ezekiel Emanuel gets wrong about physician salaries

What you say matters: An insensitive comment in the ICU

Rarely are health care professionals given the opportunity to truly ponder a crucial aspect of patient care; the truth behind what it feels like to lie in a hospital bed, vulnerable, disoriented, and stripped of every basic human dignity. I have spent over 300 days as a patient in hospitals and more than three decades […]

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A high school physical that shook this student to the core

I didn’t really notice him standing in line. But how could I? Hundreds of kids came through the high school gym yesterday. His turn for the heart and lung portion of the high school sports physical had come. He said he was going to play baseball and basketball. How could he with that arm he […]

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Why you should have your end-of-life discussion now

Draping a shroud of 30’s Depression on any dust bowl child can thicken the skin, so my 88-year-old patient learned to be fiercely independent with a “talk to the hand” attitude, and “don’t get in my way” personality. Even after her husband passed away, she remained autonomous traveling and golfing in her social circuit. Living […]

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Want to become a doctor? Ask yourself the following questions.

I keep getting served a Facebook ad from the American Association of Medical Colleges imploring me to ask politicians to fund residency training for medical school graduates. The link leads to a webpage with neat graphics and a series of well-designed cartoons dramatizing an ominous shortage of 90,000 doctors expected to occur by 2025. Continue reading ... Your patients […]

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So you failed maintenance of certification. What now?

What is it like for physicians to fail their ABMS Maintenance of Certification® (MOC) program examination? How does the largest member board of the ABMS, the American Board of Internal Medicine (ABIM), respond to doctors who fail their secure examination? Continue reading ... Your patients are rating you online: How to respond. Manage your online reputation: A […]

via Medicine Joint Channels

Mainstream media can help a physician online reputation

Is your anesthesiology practice poised for success?

When young patients become pregnant before they are ready to be parents

We’re losing the war on error. And here’s why.

What Ezekiel Emanuel gets wrong about physician salaries

This is what it’s like to be a patient. Doctors need to see this.

Florida strikes out against Brian Clement

CBC interview with Brian Clement.

Brian Clement is a charlatan. Unfortunately, that doesn’t seem to be a problem for the State of Florida. I made two (which turned into three) attempts to get the state to take action against Clement or the Hippocrates Health Institute, where he serves, with his wife Anna Maria Gahns-Clement, as co-director. All of them failed. Brian Clement slithered through the cracks in Florida law each time.

Before we get into the details of Florida’s failure to act, a bit of history (and there is plenty of it) is in order.

In recent months, Clement’s sordid cancer quackery has been well-documented in the media as well as in the science “blogosphere.” (I’ve listed what I hope is a — but almost certainly isn’t — complete blog archive at the end of this post. Many of the Canadian Broadcasting Corporation [CBC] and other news reports are linked in these posts.) Most of the coverage has centered on two Canadian girls suffering from lymphoblastic leukemia whose parents pulled them from conventional cancer therapies, which gave them an excellent chance of survival, in favor of treatment at the Hippocrates Health Institute (HHI), a sprawling spa in West Palm Beach, Florida, licensed as a massage establishment by the state.

Clement gave a talk in Canada, in 2014, claiming “we’ve had more people reverse cancer than any institute in the history of health care.” (“We” is the operative word here, because it later served as Clement’s ticket to avoid prosecution by the Florida Board of Medicine, as you shall soon find out.) The girls’ families were impressed.

Sadly, one of the girls, Makayla Sault, died earlier this year. The other, identified only as “JJ” in the media because of a publication ban, has returned to conventional treatment. However, her mother apparently remains under the influence of Clement: JJ is restricted to a raw foods diet and is still being followed, if that is the right word, by HHI.

Other cancer patients have been lured by the false hope Clement and Hippocrates offer: Stephanie O’Halloran, a young Irish woman, the parents of Anael L’Esperance-Nascimentol, a three-year old Canadian boy who went for treatment there, Laurie Ann Prince, Kathyrn Tachell and Kim Curry, also Canadians and all fairly young, and Lajos Tringer. (Tringer is also considering treatment by another cancer quack, Stanislaw Burzynski.) Most of these either drained their own resources or raised funds,or both, to pay the considerable expense of going to Hipppocrates. Unfortunately, we know that Stephanie, Kathryn and Kim have died. I’ve been unable to discover the fate of Aneal and Laurie Ann. Lajos is, as far as I know, still living, but very ill.

Orac, in his inimitable way, has described the services (for lack of a better term) offered at Hippocrates as “cancer quackery on steroids.”

Let’s take a look again at the sorts of treatments offered by Brian Clement as part of HHI’s “Life Transformation Program“. They include:

Superior nutrition through a diet of organically-grown, enzyme-rich, raw, life-giving foods

Detoxification

Wheatgrass therapies, green juice, juice fasting

Colonics, enemas, implants

Exercise, including cardio, strength training and stretching

Far infrared saunas, steam room

Ozone pools, including: dead sea salt, swimming, jacuzzi and cold plunge

Weekly massages

Bio-energy treatments

Med-spa & therapy services

Laughably, Clement claims to be a researcher who is “constantly in a position where I’m addressing medical conferences and universities,” and has “a body of evidential science ” which demonstrates why he’s observed “tens of thousands of people recovering from catastrophic disease.” Oddly enough, even though HHI has “the number one ratio of having people reverse the aging process and reverse disease than any other organization in the history of man,” a search of PubMed does not disclose a single journal article published by Clement. Really, Mr./Dr. Clement, we implore you, let the rest of the world in on your ground-breaking discoveries. Publish in a top-flight, peer-reviewed science journal, so more lives can be saved. He also claims that “we’re in the middle of a study with the University of California to disprove genetics.” Maybe that research will show up soon in the medical literature. We can only hope.

With that background, we’ll turn to the State of Florida and its failure to stop Brian Clement, who, as we shall see, has embarked on yet another international speaking tour.

Strike One: Operating a healthcare facility without the appropriate state license

I filed a complaint against Hippocrates Health Institute with the Florida Agency for Health Care Administration (AHCA) for operating a health care facility without the proper state license. (Regrettably, none of the AHCA or Florida Department of Health documents I mention in this post are available online.) AHCA licenses health care facilities, such as health clinics and hospitals. As I did with my complaint against Clement, which we’ll get to in a minute, I informed AHCA that these allegations were not based on personal knowledge, but rather upon Canadian media reports. However, in light of what I had read, I felt an obligation to report Clement and Hippocrates to the state. It appeared to me that the health of these girls and others was at stake and that it was appropriate for the state investigate what was going on.

According to a January 28th email from AHCA:

After some additional Agency research, unfortunately this “Health Center” does not meet the definition of a Health Care Clinic, see [Florida Statutes] Section 400.9905(4),

“Clinic” means an entity where health care services are provided to individuals and which tenders charges for reimbursement for such services, including a mobile clinic and a portable equipment provider.

Since this institute is a cash-only business, it does not fall under AHCA’s regulation. The only recommendation I have, is to file complaints with the Department of Health (Board of Medicine) against the individual doctors, thanks.

In other words, since Hippocrates doesn’t get reimbursed by third party payers, such as health insurance companies, it does not need a license and AHCA had no jurisdiction to do anything about the clinic.

A Senate bill was introduced this year in the Legislature to eliminate this loophole in the health care licensing law.

According to Sen. Eleanor Sobel, one of the bill’s sponsors,

flimflam artists and snake-oil salesmen have escaped state scrutiny by running clinics that accept only cash.

Like Clement and Hippocrates, for example.

It wouldn’t matter anyway. Hippocrates would have been exempted if the bill had become law (it died in committee). The licensing law exempts non-profits. The IRS has granted Hippocrates tax-exempt status as a Section 501(c)(3) charitable organization. A non-profit that, according to its 2013 tax return, paid Brian Clement and his wife, Anna Maria, together about $1 million dollars in salary, bonuses and other unspecified income, has $30 million in assets, and took in over $17 million in revenue.

What Hippocrates does have is a massage establishment license issued by the Board of Massage Therapy, for which it pays the paltry sum of $100 per year. The law seems designed to prevent houses of prostitution from operating as fictitious massage parlors, but rank quackery doesn’t appear to be a problem as far as licensing goes.

Strike Two: Department of Health v. Brian Clement, Case No. 2014-19139

On November 13, 2014, I filed a complaint with the Florida Department of Health against Clement for practicing medicine without a license. (The Medical Quality Assurance [MQA] division of the Department investigates unlicensed practice complaints as well as complaints against licensed health care practitioners.) I explained to the MQA that I didn’t have any personal knowledge about Clement’s conduct, but was reporting him based on news stories covering Makayla’s and JJ’s treatment at Hippocrates, including the report that his degrees were from diploma mills and the fact that he is not a state licensed health care practitioner, although he says he’s an NMD on HHI’s website. I specifically included his statements about “reversing cancer,” Makayla’s grave medical condition at the time (I later reported that she had died) and the fact that HHI was continuing to provide care by analyzing the child’s blood test results which are sent by mail. Later, I spoke to an investigator with MQA and gave her links to the HHI website and to a number of Canadian media reports.

On February 10, 2015, the Department of Health issued a “Notice to Cease and Desist” in the case, stating that

the Department has probable cause to believe that Brian Clement of Hippocrates Health Institute . . . is not licensed by the Department or the Board of Medicine and is practicing medicine without a license. . . .

Wherefore, . . . Brian Clement . . . is hereby notified to cease and desist from practicing medicine in the State of Florida unless and until Brian Clement is appropriately licensed by the Department.

The Department also ordered Clement to pay a fine of $2500 and costs of $1238.

On February 16th, an “Unlicensed Activity Investigative Report” was issued by the Department. As investigations go, it seems pretty cursory. It contains copies of only two of the many news reports and one of the many blog posts. Also attached are printouts from the HHI website detailing the appalling quackery offered there, which seems to have bothered exactly no one at the Department.

An investigator went undercover to an appointment with Clement, which elicited, as might be expected, only quack recommendations (including the sale of merchandise from HHI) but no smoking gun statements to the effect that Clement is an MD or specific medical diagnoses or treatments.

The report says that the investigator did not attempt to obtain a release of patient information authorization from the Canadian girls because “their names were not provided or noted in the Canadian News Release,” even though Makayla’s name is clearly given in one of the news stories attached to the investigative report itself, as well as in links to other information provided by me. And it seems that the Department could have at least attempted to discover the identity of JJ through contacting the Canadian government. After all, the ban is on publication of her name, not giving it to the authorities in another jurisdiction doing an investigation of alleged criminal activity. (Practicing medicine without a license is a felony in Florida and, according to the Department, the Sheriff’s Office was notified, although I have a feeling that one will go nowhere too.)

Another person not contacted was Steven Pugh, RN, who is suing HHI and Clement over his being fired for refusing to follow Clement’s orders. According to a CBC news report, published well before the investigative report was issued, Pugh maintains he could not legally do what Clement told him because the orders were not issued by an MD. Pugh also reported to the CBC that Clement told patients he could “cure” them, prescribed treatments for them, would overrule what their physicians told them and used the term “Dr.” with patients (as he formerly did on the HHI website). Most disturbingly,

They (Clement and his wife) also placed restrictions on when staff could call an ambulance to take patients for emergency medical care at local hospitals, according to Pugh and other former staff.

According to this same news story, the CBC has interviewed both past and present employees who are disturbed by the Clements’ treatment of cancer patients. It also reports that a former HHI physician is suing for breach of contract, alleging he was terminated after he documented concerns that what he was being asked to do at HHI could be illegal.

A search of the public records (in this case, the of the 15th Judicial Circuit Court) would have revealed Pugh’s suit, along with two others, against HHI. You’d think a decent investigation would, at the very least, include a search of the public records of the state doing the investigating.

All of this leads me to conclude that the Department should hire the CBC to do its investigations. They do a much better job.

Much to my surprise, I learned from – you’ll not be surprised to learn – the CBC, that the Department, citing insufficient evidence, had dropped all charges against Clement. I called the Department for more information but my call was never returned. Later, when I called about the Department’s second complaint against Clement (see “Strike Three,” below), I was told by a Department official why they couldn’t prosecute Clement for the unlicensed practice of medicine. He explained that HHI has a physician on its staff and, by Clement always using the collective “we” ( as in, “we can reverse cancer”), he personally was not practicing medicine.

Since we’re on the subject, HHI has a new physician as Medical Director, Tina Discepola, MD. I wondered what sort of physician would associate herself with an operation like HHI and a guy like Clement, especially in light of their well-publicized troubles. Even if you fully believed in what they were doing, you’d have to be wary of stepping into the hornet’s nest of litigation and on-going investigations by the Department of Health. (Pugh has filed his own complaint against Clement.)

In any event, Dr. Discepola is certainly well acquainted with, shall we say, unconventional medical practices. According to her HHI bio, although board-certified as an emergency medicine doctor, she formerly practiced Functional Medicine in New York. She is also into acupuncture and cranial sacral manipulation. She is a Diplomate of the American Board of Integrative Holistic Medicine, Andrew Weil’s brainchild, a Diplomate of the American Board of Anti-Aging Medicine (also, here) which is not recognized as a specialty board by any of the medical specialty-credentialing organizations, and is an “active member” of the American College for the Advancement of Medicine, ditto.

Curiously, while she holds an active license to practice medicine in Florida, according to the Department of Health’s Practitioner Profile, she still lists New York as her residence and states that she does not practice in Florida. I understand that Dr. Discepola is new to Florida, and is likely unfamiliar with the laws and regulations governing medical practice in this state, but she may want to review them, including the state’s rules on physician advertising.

Dr. Paul Kotturan, the former Medical Director, is still on staff, running the “Vida Building” operation, which must surely contain more quackery per square foot than any other building in the state, including, for example, the Aqua Chi ionic detox footbath, which, if it works as advertised,

Your meridians are permeated and re-aligned back to their original strength and placement.

If there is a medical device equivalent of homeopathy, the detox footbath is it.

Strike Three: Dietetics & Nutrition Practice Council v. Brian R. Clement, Case No. 2014-19150

In a letter dated March 24, I learned that this complaint had been reviewed by legal staff and recommended for submission to the next Probable Cause Panel. It was another surprise from the Department for me, because I didn’t even know this particular complaint had been filed. This time, according to the complaint, it was because Clement illegally used the initials “NMD,” which stands for “Naturopathic Medical Doctor.”

Clement is a licensed nutritional counselor in Florida, but is not an NMD. (Florida used to licensed naturopaths, but stopped issuing licenses in the 1950s, although the state allowed those with ND licenses to continue their practices. To my knowledge, none of these licensees are still practicing.) As with all types of health care practitioner licensing, nutritional counselors are required to follow certain laws and administrative rules. The complaint alleged Clement violated three separate provisions in advertising himself as an NMD.

Based on this, one might say that the Department of Health is charging Clement with practicing quackery without a license, but that’s not how they see it.

“Nutrition counselors” are no longer licensed in Florida either, but those, like Clement and his wife, who hold nutrition counselor licenses, can still practice. The state now licenses only registered dietician/nutritionists, who must meet more rigorous requirements than nutrition counselors. Neither of the Clements have the qualifications for the newer license, at the least because they didn’t graduate from an accredited school nor have they taken the current licensing exam.

Nutrition counselors are, by law, limited in their practices to advising people on appropriate nutrition intake by integrating information from an evaluation of nutritional needs, using appropriate data to determine those needs, and making appropriate nutrition recommendations.

It is striking to me that, given the reams of material documenting Clement’s inappropriate nutrition advice, it never occurred to the Department to add a count or two to the complaint for substandard practice as a nutritional counselor. What about wheatgrass, which, as Orac points out, Clement seems to regard as a virtual panacea, and raw foods diets? And what about wheatgrass enemas? is that an “appropriate” nutrition recommendation?

In the Department’s investigative report, mentioned earlier, we learn that the investigator reviewed the Hippocrates website and confirmed that Clement was using the title NMD. (Gee, notice anything else, Mr. Investigator?) The report notes that Clement had been issued an informal Notice to Cease and Desist in the past for advertising and using the title NMD on the website. Later, when the undercover investigator revealed his true identity, Clement denied using the title “Naturopathic Medical Doctor” on the Hippocrates website, despite all the evidence to the contrary.

Brian Clement no longer uses the honorific “Dr.” nor does he list the initials “NMD” on the website. He still uses PhD on his bio page, and the covers of book advertised at the bottom of the page identify him as being an NMD. He says nothing about where he earned any of the claimed degrees. He has been referred to as “a naturopath” or “Naturopathic Medical Doctor” in a couple of news reports, information they must have gotten from somewhere. (Also: “a formally trained biochemist.”)

Clement has variously claimed his degrees came from University of Science, Arts, and Technology (USAT), where he says he earned his PhD and NMD, and Lady Malina Memorial Medical College, where he says he earned a post-grad degree. (Interestingly, for both Brian and Anna Maria, no undergraduate degree is ever mentioned.) But those institutions have been called out as diploma mills in both a CBC report and academic literature. The president of USAT denies Clement was granted an NMD degree by his school.

Anna Maria Ghans-Clement’s HHI bio say she has a PhD in nutrition from “Denmark University” but I could not find that any such institution exists. It refers to her as “working on her nursing degree,” implying that she has one, but does not say whether the degree requirements were completed. Her book covers also show her as having an NMD and one of her book covers shows the book as being authored by “Dr. Anna Maria Clement.”

Nevertheless, once again, the Department backed off. According to the Department’s letter to me of May 20, the probable cause panel determined that probable cause existed to support prosecution of Clement for allegations set forth in the complaint. However,

after the finding of probable cause, the Department discovered correspondence from [Clement’s] counsel that was not available to the probably cause panel during consideration of the case. As a result of this new information, the Department dismissed the Administrative Complaint due to insufficient evidence to prosecute.

They don’t say what information was “discovered” in this letter. A Department official did tell me in a phone conversation that Clement does, in fact, have an NMD degree and that, while he can’t practice as a naturopath, he is not prevented from using those initials after his name. I informed the official that, to my knowledge, he does not have an NMD degree, information that seemed to surprise him. In fact, the denial was reported by the CBC (yes, them again) in 2014, well before the Department acted.

So, where in the world is Brian now? According to his busy speaking schedule, he is, a this moment, at the “Real Truth About Health” conference in Orlando, where he is identified as an NMD. Then he is off to New York to lecture. (At the Manhattan lecture, attendees will get 10% off HHI’s 3-week “Life Transformation Program,” a “$600 value.” Which means, if you do the math, the 3 weeks normally costs $6,000.) After that, it’s Europe: Norway, Sweden, the UK (he’s still a naturopath according to one of the London announcements), Ireland, Germany (“Dr. Clement”), France, Switzerland and Holland. The announcements indicate Clement is being circumspect about what he says, but who knows what he’ll do when he actually gets there. Clement doesn’t seem like the type who can resist grandiose pronouncements regarding his many self-proclaimed talents. And, of course, once within the confines of the vast acreage of the privately owned (but taxpayer supported) Hippocrates campus, he is virtually free from scrutiny.

The Brian Clement/Hippocrates Health Institute Blog Archive

Science-Based Medicine

Ontario fails to protect the life of a first nations girl with cancer

Brian Clement and the Hippocrates Health Institute finally under the spotlight, but will it matter?

An aboriginal girl dies of leukemia: Parental “rights” versus the right of a child to medical care

Florida tells Brian Clement to stop practicing medicine

Respectful Insolence

When false hope leads well-meaning people astray

An Ontario court dooms First Nations girl with cancer

An Ontario court dooms a First Nations girl with cancer: Who’s to blame?

A tale of two unnecessarily doomed aboriginal girls with leukemia

J.J. has a chance to live!

Finally, the State of Florida acts against Brian Clement and the Hippocrates Health Institute

Brian Clement and the Hippocrates Health Institute: Cancer quackery on steroids

Society for Science-Based Medicine

Canadian reporters cover Florida health scam ignored in US

Florida retracts cease and desist order and fine against Brian Clement

Florida files second complaint against Brian Clement

Other blogs

The Seduction of Cancer Quackery

Hippocrates Health Institute: Five reasons not to spend $4,000

Staff of controversial Florida alt med spa sues claiming illegal and unethical practice

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Research and Reviews in the Fastlane 085

Welcome to the 85th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Critical Care

Vourc’h et al. High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: a randomized controlled clinical trial. Intensive Care Med 2015. PMID:25869405

An interesting paper if you adhere to NODESAT (Nasal Oxygenation During Efforts Securing a Tube) and believe that apneic oxygenation may help your patients avoid desaturation during intubation. The authors in this RCT compared High Flow Nasal Cannula (using a specialized cannula) to usual face mask preoxygenation in hypoxic ICU patients and found no difference in desaturation events between the two groups (despite having HFNC on throughout the procedure). I doubt it will change your practice, but may make you think twice about purchasing the specialized equipment needed for high flow nasal O2 for this indication – just keep using the good old nasal cannula for now and crank up the O2 once the pt is sedated.
Recommended by: David Marcus

The Best of the Rest

Cardiology, Social Media

Fox CS et al. A randomized trial of social media from Circulation. Circulation 2015; 131(1): 2833. PMID: 25406308

Great name: Intention to Tweet, a well-designed RCT in Circulation showing that tweets from journals don’t drive web traffic. Except they used a straw man intervention and cardiologists probably don’t use twitter as much as ER docs.
Recommended by: Seth Trueger
Read More: Letter by Thoma et al regarding article, “A randomized trial of social media from Circulation”. PMID: 25825403

Emergency medicine
Hakemi EU et al. The prognostic value of undetectable highly sensitive cardiac troponin I in patients with acute pulmonary embolism. Chest 2015; 147(3): 685-94. PMID: 25079900

High sensitive troponins (HST) are making its way into the field of acute coronary syndrome and now into pulmonary embolism. This study was a retrospective cohort study of 298 patients with confirmed PE. In this population, a 45% were HST negative while 55% were positive. From the HST-negative group, there were no death, CPR or need of thrombolysis compared with 6% of mortality and 9% of CPR or thrombolysis in the HST-positive group. It appears that HST is a good prognosis biomarker in patients with pulmonary embolism.
Recommended by: Daniel Cabrera

Emergency medicineLin BW. A Novel, Simple Method for Achieving Hemostasis of Fingertip Dermal Avulsion Injuries. J Emerg Med 2015. PMID: 25886984

Fingertip avulsion injuries are typically frustrating to repair. This article reviews a simple method for fixing these injuries using tissue adhesives.
Recommended by: Anand Swaminathan

Critical Care
Loubani OM et al. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care 2015; 30(3): 653.e9-653.e17. PMID:25669592

In critically ill patients, with hemodynamic instability, vasopressor infusion through a proximal PIV (antecubital fossa or external jugular vein), for <4hours of duration is unlikely to result in tissue injury and will reduce the time it takes to achieve hemodynamic stability.
Recommended by: Salim R. Rezaie

Research and Critical Appraisal
Wears RL. Are We There Yet? Early Stopping in Clinical Trials. Ann Emerg Med 2015; 65(2):214-5. PMID: 25601251

This is a brief editorial on the concerns and dangers of stopping trials early. Dr. Wears delves into appropriate reasons to stop trials early (lack of funding, futility, similar research published rendering the question moot) and inappropriate ones. He also explores ways we can improve the construction of research to make it more likely to yield usable findings. A must read for those critically appraising the literature.
Recommended by: Anand Swaminathan

The R&R iconoclastic sneak peek icon key

	The list of contributors		The R&R ARCHIVE
	R&R Hall of famer You simply MUST READ this!		R&R Hot stuff! Everyone’s going to be talking about this
	R&R Landmark paper A paper that made a difference		R&R Game Changer? Might change your clinical practice
	R&R Eureka! Revolutionary idea or concept		R&R Mona Lisa Brilliant writing or explanation
	R&R Boffintastic High quality research		R&R Trash Must read, because it is so wrong!
	R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

The post Research and Reviews in the Fastlane 085 appeared first on LITFL: Life in the Fast Lane Medical Blog.

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