CodeBlueBlog

CSI MEDBLOGS: THE POISONING OF VIKTOR YUSHCHENKO

The Opinion of a Consultant

I know a lot of opinions have been put forth in the Blogosphere recently rearding Viktor Yushchenko's facial transmogrification. Wizbang set off the fireworks and diagnoses were running rampant on the net thereafter. Highly respectable Blogs like Interested-Participant and Medpundit took a stab at a diagnosis (Leprosy -- that was titillating and awesome to imagine) while Flit found someone ready to diagnose cutaneous  T-cell Lymphoma (look out for that!) and thereafter spurring several of my readers to write me asking for my take...

I've only had a few hours with the Viktor Yushchenko photographs, so I'm going OUT onto an iced-up limb here. As some visitors to this  blog might know, however, I'm NOT afraid to set down my opinion. Here it is:

Name your Poison

Viktor was indeed poisoned. By himself. That is, he drinks too much; and, he has a common skin disease. That's what I think. Follow me for a few minutes.

ONE: NO ONE could look at these photos and tell you what is wrong. First of all, there's not enough evidence, the lighting is not consistent, the detail is different on each photo, we don't know what the rest of his skin looks like, and we have VERY little clinical data to go on...but finally, realize, that with Photoshop out there these could be pictures of V.Y.'s Borzoi sniffing at the door of a porta-potty, cut and pasted to look like a respectable but poisoned Ukranian leader. You just can't trust them...and you shouldn't.

TWO: NO ONE, as usual, could read what the press or major media reports about this and cogently put together the likely illness because the PRESS and MAJOR  MEDIA get just about everything in healthcare WRONG and when they don't get it wrong they mess up the data so that you don't whether headaches are associated with burning on urination or pimples are a complication of flat feet. You just can't rely on how the press transcribes what the doctors and clinical records tell them.

A Horse is a Horse

So all I can do is evaluate what we are all presented with and give the MOST LIKELY SINGLE DIAGNOSIS to explain it all. That's what my professors DRILLED into my head. First: the patient gets one diagnosis. Second, likely things are likely (or, when you hear hoofbeats don't expect to see Zebras come around the corner--it's going to be a HORSE).

This is about the only half-sane medical info I could cull from the press reports:

Doctors were unable to confirm suspicions of poisoning because Yushchenko first checked into the clinic four days after the symptoms appeared -- too late for tests to show if poisoning had occurred, Korpan said.

At Rudolfinerhaus, Yushchenko underwent a week of intensive treatment for several illnesses, including acute pancreatitis, a viral skin disease and nerve paralysis on the left side of his face, Korpan said.

. The Corner of Fifth and Vermouth

Take this photograph to any Betty Ford Treatment Center Kiosk  in the country and ask them what they think this guy does every night other than sleep.

Do they make Stoli in the Ukraine?

If you see this picture enlarged you can appreciate the spidery red flush around his MALAR area (nose, under the eyes).

By history, V.Y. was doing fine until September when he had a BIG, important dinner with Ihor Smeshko, the head of Ukraine's internal security services. Four days later he checked in to some unpronounceable Vienese clinic (how do you translate AA?) to be treated for ACUTE PANCREATITIS -- a disease almost exclusively suffered by...alcoholics.

As an immunologically impaired alcoholic, V.Y. could  easily be infected with pathogens and it is not hard to postulate that he at some point picked up a virus, and displayed the rash of viremia (virus in the blood), ending in left facial paralysis ( = Bells Palsy  a not-unusual complication of viremia).

It's the Bell's Palsy which causes him to wipe his eye -- his eyelid is paralyzed and doesn't blink.

But, I know what you are asking. How did Vikto wind up looking  like Theodin (son of someone)  possessed by Wormtongue ? Or, THIS:

Well, to get to THIS final face, of the three faces of Yushchenko, we have to make one final stop on the diagnostic railroad: Rosacea (parenthetical remaks are my translations):

Rosacea is a common condition characterized by symptoms of facial flushing and a spectrum of clinical signs, including erythema (redness), telangiectasia (spidery vessels visible on the face), coarseness of skin (see above), and an inflammatory papulopustular  (bumps and pimples) eruption resembling acne.

There is BIG FACTOR that makes Rosacea worse. And it's not running for the presidency of the Ukraine. It's alcohol:

Alcohol is among the scores of different triggers that can prompt or aggravate rosacea flare-ups in some patients. While drinking causes fewer reactions than "the big three" -- sunlight, heat, and environmental stress -- a new survey shows that just one alcoholic drink can trigger problems in two of three patients.

According to eMedicine:

Rosacea affects the central flush/blush areas of the face, (i.e forehead, nose, cheeks, chin), although ocular disease and extrafacial lesions are well-recognized features...Sebaceous hyperplasia (overgrowth of lumpy oil glands), fibrosis (hard, nodular tissue), and lymphedema (generalized swelling) characterize more severe forms of the disease...Prominence of sebaceous glands may be noted with the development of thickened and disfigured noses ..Ocular lymphoedema (swollen eyes) may be prominent ...Both seborrhea and seborrheic dermatitis/blepharitis (skin inflammation/eyelid inflammation) are not uncommonly observed in patients with rosacea.

Sometimes a Foible is Just a Foible

So, as much as we all want our leaders to be involved in the glamor of poisonings and radiation burns and mutants from another galaxy, most often they are afflicted simply with foibles -- and those are worse than pimples, but better than Leprosy.

      STAY TUNED

hat tips to: Off Wing Opinion 

                  The Glitteringeye

                   opinionbug

**ADDENDUM NOTE of 12/02/2004**: a follow-up post to this article can be found ON THIS BLOG AT:

http://codeblueblog.blogs.com/codeblueblog/2004/12/csi_medblogs_na.html

CSI MEDBLOGS: QUESTIONS AND THEORIES: THE MYSTERY OF MARY MCCLINTON'S DEATH DEEPENS

On November 4th, 2004, Mary McClinton was placed on the procedure table in the radiology department of Virginia Mason Medical Center (VMMC) in Seattle, for the nonsurgical treatment of a cerebral aneurysm. This is a recognized procedure (info here) with a good safety profile.

Who, What, When, Where, and How?

Something went wrong during the procedure and two and a half weeks later, Ms. McClinton was dead. According to many published accounts:

At the end of Mary McClinton's recent operation, a technician was supposed to inject a harmless marker dye used for X-rays into a leg artery. Instead, the syringe was filled with chlorhexidine, a toxic antiseptic used to clean the skin

CodeBlueBlog has previously raised questions regarding the proposed chronolgy of this mishap (here and here). Two additional physicians have added to the comment sections of these posts, raising further issues.

Here are the questions:

1. Why was the leg artery injected at the end of a brain procedure? 

2. Why was a technologist performing the injection?

3. Was a mechanical injector used or was this a hand injection (a "syringe filled with chlorhexidine" implies a hand injection).

4. How much chlorhexidine was injected?

5. Is it being proposed that the chlorhexidine was directly responsible for all the damage that ensued (including reported kidney failure and a cerebral infarction), or was the leg primarily damaged with the remaining problems resulting as complications of leg necrosis, compartment syndrome, gangrene and the ensuing medical and surgical interventions?

These Puzzle Pieces Don't Interlock

According to the Journal of Toxicology, the lowest possible lethal intravenous dose of chlorhexidine is 13mg/kg. If Ms. McClinton were approximately 60kg and the chlorhexidine disinfectant solutions generally available range in concentration from 0.5% to 2.0%, it is hard to imagine a volume less than 50cc causing death.

Besides, The Journal states the organ of injury as the lung with pulmonary toxicity and pulmonary edema developing. This was not mentioned as a complication in Ms. McClinton's case; however, there are, presumably, different sequelae between intravenous and intraarterial administration. There just isn't any literature on arterial misadministrations.

The hospital reports that a technologist injected the chlorhexidine, drawing it from a bowl on the procedures table. The largest hand injections done this way are usually no more than 10-20cc. In addition, since patients are awake during these procedures, I would imagine that the pain induced upon injecting this substance into Ms. McClinton's leg would have ellicited a scream of pain. It is therefore doubly difficult to imagine that a large amount of this substance was pushed through a syringe into her femoral artery.

So we have an off-procedure event (injecting the femoral artery during a cerebral angiogram), puportedly done by a technologist (is that standard at VMMC?), using an amount of material that would seem not voluminous enough to be the primary and direct cause of all the damage ascribed (leg necrosis, kidney failure, cerebral infarct) and then leading to a protracted death, drawn out over  21/2 weeks. The hospital's own memo calls the  chlorhexidine "highly toxic"  and they make the effects of this injection seem quite severe and systemic. By the words of spokesman Dr. Caplan:

The cleansing solution basically acted as a poison, which caused widespread damage to the organs of her body

Well, if this were such a toxic poison, and the effects of it's injection were so catastrophic and widespread -- why did it take her 2 1/2 weeks to die?

For Once, I Hope I am Wrong

I believe that the catheter or sheath (a tube that holds the catheter in the groin/femoral artery) was injected with a small-to-moderate amount of chlorhexidine disinfectant preparation. Of note, most chlorhexidine  preparations that I could find were based in alcohol. Alcohol is a potent sclerosing agent -- in fact we used to occasionally use alcohol to sclerose renal cysts.

It is more likely that the combination of chlorhexidine and alcohol caused obliteration of the vascular supply to Ms. McClinton's lower extremity. She then could have developed a severe, unretractable compartment syndrome (a pdf on it here) with ensuing gangrene necessitating an amputation. Her death, therefore, from systemic complications surrounding this event, would NOT be due to the chlorhexidine injection per se; rather, it would be secondary to the complications of lower extremity gangrene, the treatments required for this condition, as well as the timeliness and appropriateness of those treatments. 

This raises a new large set of questions for VMMC regarding their treatment of Ms. McClinton following the damage done to her leg. I will not speculate here without giving the hospital a chance to reply.

I sincerely hope my scenario is untrue. Because if it IS true, then VMMC's whole act of contrition is called into question as well as the type, nature, and timeliness of Mary McClinton's care after the misadministration.

I think the hospital needs to release another memo. This time to the public. There's explaining to do.

We'll wait to see if we hear from the VMMC.

Stay Tuned.

CSI MEDBLOGS: FURTHER INVESTIGATING MARY McCLINTON'S DEATH...THE MEDICAL BLOGGISTS POOL EXPERTISE

What follows is a comment left on this site, today, by Bard-Parker and my response, which is at first an apology for a disorganized post that got published prematurely, and then a follow-up on the story regarding Mary McClinton -- the Seattle woman who died horribly after disinfectant was accidently injected into her common femoral artery...I hope it clears up some of the misunderstandings generated by my post earlier.

Thanks to Dr. B-P.

From Dr. Bard-Parker:

The preps my radiologists use are breakable ampuoles within a plastic tube that fills a brush so such things can be avoided.

I have two aditional questions:

Aren't such post-coil films done with a power injector? If it was then the "technologist injection" may not be implausable since the tech would load the injector and push the button to begin the digital subtraction and injection.
How toxic is chlorhexidine? It is in things that range from Peridex mouthwash to Surgilube. I'm sure that it's not smart to inject such thing but how much would be required to have the effect advertized?

My Response:

First,let me apologize for how this post published. Typepad is driving me crazy today. This post published on first PREVIEW, before spellchecking, and also missing several key items including info/literature on chlorhexidine; pics and routine description regarding cerebral embolization technique; studies regarding the appropriateness of embolization therapy  in nonruptured aneurysms, as well as which centers should be doing this procedure. Now TypePad is not letting me edit the post and my only recourse is to delete it, which I won't do; so, I will update this weekend with those missing data, in a second slightly more coherent format.

There used to be a fear that sponges and plastic applicators could "microfragment" and then become implanted during the Seldinger stick of the common femoral artery (this is the arterial puncture that begins the entire procedure) leading to foreign body granulomas, infections, etc. I think newer materials have eradicated that possibility and your guys are certainly using the right applicators; in fact VMMC is now using those same ampule-applicators.

I considered the whole chlorhexidine angle early on. I had the exact same thought as you do. It's hard to believe. I mean what did they do, inject a janitor's drum of that stuff in her?

There isn't much in the literature out there regarding intravenous administration of this stuff, so I didn't really have enough ammo to question this mechanism (I'll post my research over the weekend); and the couple of incidents regarding chlorhexidine complications seemed pretty dramatic. I realize that I could be missing a HUGE story, but I let it slide for two reasons: 1. I was going to come off as over-conspirational and thus undermine my credibility; and, 2. I have enough evidence to prove what I want to prove: that VMMC is using the "PR" game in an immoral way that, in the end, is going to back-fire and hurt EVERYONE in the medical field.

Most newer-trained neuroradiologists will use the power injector. In a recent survey, only 5 of 70 or so Rads said they were still ONLY hand injecting. I considered the power injector scenario and it raised an interesting point. The injector (which, depending on the model -- single or double barrell -- holds 60-300cc's of contrast) would have been filled at the beginning of the procedure. Surely they had done several limited runs before this last incident; so, if they were using the injector then there was CONTRAST in the injector. Each CCA run is about 10-12cc's and an ICA run is about 7-8cc's...it's hard to imagine they didn't load enough contrast.

But if they did miscalculate the amount of contrast needed then someone would have had to dip the nose of the power injector down into the chlorhexidine and manually crank it backwards into the injector and then rehook-up the catheter for that last, fatal injection.

That may well have happened, but there was no mention of any of these machinations in any reports.

If we assume they are telling the truth about the chlorhexidine injection, then I believe the most likely scenario is that someone grabbed a syringe, reached over and quickly sucked up fluid from the "wrong" bowl and injected it.

A hand injection can never be done by a technologist.

Even in the case of the power injector, the Doc is obligated to check the injector, and attach the tubing to the catheter himself before allowing the tech to operate the apparatus.

Question remains: how did they inject the patient's the leg? Were they doing the leg on the way out ( while removing the catheter after completing the cerebral exam) to work up claudication? Did they screw up the line (i.e. it stopped working and they couldn't figure out why), pull the catheter and inject the sheath (there is a sheath in the artery through which the catheters are exchanged) to see what's up?

COME CLEAN

One of the points I was heading to (until fouled by TypePad) was that I TOTALLY agree with the concept VMMC pays lip service to : coming clean. They should come clean and go from there. But, you see, they are not only NOT coming clean, they are, instead, putting on a dog and pony show concocted by their PR firm...and it is SO transparent it is insulting, and I don't think people will go for it for too long. Then, when the truth comes out, and it blows up into pieces it will engender MORE antipathy against physicians and fuel the litigating lions out there.

That's why my advice is for them to fess up and answer-up. In excruciating detail.

Maybe I'm too cynical (who me?) and VMMC is just REALLY bad at PR and didn't mean to present such a distracted, uncoordinated, illogical story to the public (after all, 160 consecutive media stories caught on to NONE of these contradictions)...because maybe those hospital administrators care less about their jobs then about the wide world of medical errors and patient safety. Maybe.

But it's also possible that the screw-up here is worse than "systems" failure and they are shucking oysters like mad hoping to bury us all in the shells...I know where I'd place MY bet.

Thanks for your letter.

CSI MEDBLOGS: A DEATH IN ERROR...WHAT HAPPENED TO MARY McCLINTON?

On November 4th, 2004, Mary McClinton entered the Virginia Mason Medical Center (VMMC) for an elective procedure involving a nonsurgical treatment for an incidentally discovered cerebral aneurysm. Almost three weeks later, Ms. McClintock was dead, after suffering massive intravascular damage caused by the inadvertent injection of a disinfectant. After reading all 160 news reports on the Web, portions of a "memo" released to the Seattle Times, and the VMMC website, I have laid out the bizarre circumstances of this occurrence, and, in the process raised many question -- and many doubts -- about the explanation for this disaster.These are questions yet to be answered, and doubts yet to be addressed. My analysis follows.

n.b. A synopsis is contained in Part I, if you don't have the time for the whole post; Part II is a more detailed evaluation; Part III is opinion, excoriation, and questions.

HAT TIP TO KEVIN, M.D. FOR THE LINK

PART I: Minimalism

The Nutshell:

Otherwise healthy 69 year old Mary McClinton was incidentally found to have an unruptured cerebral aneurysm (an abnormal outpouching of an arterial blood vessel in the brain -- these can bleed).

Ms. McClinton went to Virginia Mason Medical Center (VMMC), in Washington, to have the aneurysm fixed by a nonsurgical, minimally invasive procedure called transcatheter embolization (done in the radiology department usually by an interventional neuroradiologist)

How It's Done: The groin is washed off, draped, and anesthetized. A scalpel wound is made and a needle is stuck into the femoral artery. A wire is then passed through the needle, the needle is removed, and a catheter is passed over the wire, threaded up to the aneurysm, in the brain, and small coils are passed through the catheter and dropped into the aneurysm until the anurysm clots off. The catheter is then pulled back to the level of the neck and  iodinated contrast ("dye") is injected in order to view the result.

While on the table, we are told that towards the end of the exam, McClinton was injected with cleaning fluid instead of contrast medium, and she died as a result.

The Nut:

The story of how this catastrophic error was made -- reconstructed through reports in the media and from a memo released by VMMC -- makes no sense. VMMC’s rationale of why and how this catastrophic error occurred is vague, contrived, and full of holes. Furthermore, VMMC makes a shameless PR play as champions against medical errors in the face of this momentous mistake, and this despite their poor record of safety in the past.

Here are the available excerpts of the memo from The Seattle Times:

PART II:  Pointillism

According to the memo issued by VMMC:   (italics mine) 

1.  at some time during the procedure a bowl of colorless disinfectant (used to clean the skin before needle puncture) was put on the doctor’s procedure table right next to an identical bowl containing colorless iodinated contrast material (injected into blood vessels during the exam rendering them visible by X-ray)

2.  the disinfectant was confused with the contrast and was inadvertently injected instead of the contrast

*3. a technologist purportedly injected the iodinated contrast.material

*4. this mistake was made at the end of McClinton's procedure as physicians wanted to check the status of the thrombosed aneurysm

5. The antiseptic was injected into a main artery carrying blood to the leg

6. the antiseptic caused profound injury and swelling of the leg; and, kidney failure, a sudden drop in blood pressure and a stroke followed.

7. VMMC publicly admits that this constitutes a deadly medical error, part of a stunning American statistical group of 98,000 purported to occur every year

  8. However, this particular medical error was actually due to a systems problem and no individual is responsible

9. In fact, VMMC has actually made a firm commitment to eliminate errors from its system entirely -- by establishing processes that bring errors to the forefront for examination

*These points were made in news reports but not quoted as being from the memo per se

Point by Point, Here Is What’s Rotten in the State of Virginia Mason:

1.        …during the procedure:

the disinfectant is used to clean the groin before the patient is draped and before the femoral artery is penetrated. Most of the disinfectant should have been used at that point, making the liquid volume in the bowls notably disproportionate…why does VMMC keep making the point that the disinfectant was put on the table “at some point during the procedure”?

2.            …confused with the contrast

although during this type of procedure I can postulate how the two clear fluids became juxtaposed; most times, experienced professional angiographers should be able to tell (sight, smell, feel, viscosity, behavior) the difference between iodinated contrast and cleaning fluid

3.         …a technologist…injected

All the news reports indicate that a technologist was supposed to or actually did inject the cleaning fluid instead of the contrast

I find this hard/impossible to believe. Catheters in place to study the brain are always injected by the physician, and if the technologist did do this injection, then this is another “systems problem” at VMMC

4.            …this mistake was made at the end of McClinton's procedure

a key point

at the end of this type of procedure the catheter is retracted to the level of the carotid artery (in the neck) and the catheter is injected in order to opacify the distal carotid circulation to check the status of the now thrombosed aneurysm

if disinfectant were injected at this point, as they indicate, it wouldn’t be her leg that melted, it would have been her brain

5.         … injected the leg

as per # 4, it is not the leg (meaning a direct injection of the common femoral artery at the level of the groin) that is injected at the end of this procedure, it is the carotid artery in the neck. There is nothing, in any report or in the excerpts from the memo that would justify injecting her leg

6.         …a stroke followed

all the reports and the memo excerpts report that Mary McClinton had a stroke (a cerebral infarction) and everything written makes it seem as if the stroke occured as a result of the chlorhexime injection; however, how did she stroke if they actually did inject her leg; and, how bad was the stroke if she were able to call her son two hours later to complain of pain, and likewise receive her son as a visitor that night to again complain of pain and swelling? So, chronologiocally, when did the stroke occur, what caused it, and how bad was it?

7.         …a stunning statistic

This really angers me. VMMC makes a catastrophic, inexcusable error of the highest magnitude and then they spin themselves as some kind of champions against medical errors who are stunned at the number of deaths from medical errors each year in America (numbers that are wildly overblown, I might add, from an IOM  study that, I think, had a lot of problems...download here)

8.      a systems problem…no individual is responsible

a systems problem? I should really roast them for this, but they are already so deep in black duff, it would be like kicking a dead animal. That is patent nonsense and insulting to everyone who reads it. There certainly is an individual responsible here and if you would like, I can think of precisely three people who should step forward and take responsibility for this.

9.                  …a firm commitment to eliminate errors...bringing them to the forefront for examination

PART III:  POST MODERNISM

VMMC got high marks from the knee-jerk press for owning up to injecting cleaning products into a patient. And their medical director of quality, Robert Caplan M.D. -- with cogliones as big as stuffed veal chops– actually had the nerve to start lecturing, on the hospital’s website, about the “medical error” problem in America (I guess it STARTS in Seattle)! Caplan cites that outrageous Institute of Medicine (download it here) article (the one that confabulates unreal numbers for deaths from medical errors and is now all but taken as fact) and then, in a stunningly bold, almost Clintonesque move, he suddenly takes the stance of a champion for eliminating errors! Wait! I thought this was an apology? From the VMMC website apology for Mary McClinton's death:

Virginia Mason has made a firm commitment to eliminate errors from our system entirely -- by establishing processes that bring errors to the forefront for examination, and by developing systems to prevent such errors in the future.

Sounds like a very retrospective approach to me…I’d rather go at it from the other end of the process, but nonetheless, the whole “Bless me father for I have sinned” routine has come off smashingly well in the press and also with the victim’s family (just wait though, Bob, till the Torters come a callin’), and I have to say, job well done, Dr. Caplan. It must have cost a fortune in consultant’s fees to come up with that.

Well, I think we will not let Dr. Caplan or Virginia Mason off that easy, eh? After all, in the same paragraph on the hospital’s website the medical director says:

Open discussion of medical errors is essential, because it provides the best opportunity to understand what actually happened and to teach others the important lessons that have been learned.

Okay, I’m ready for some open discussion.

WHICH SYSTEMS ARE WHICH?

First, let’s just get one thing out of the way:  this tragic error isn’t any nonsensical VMMC “systems problem,” and the transparency of that dodge will probably show up like beefsteak tomatoes on the salad of a litigator soon.  Then to boldly go on by saying that  “no individual is responsible,” makes me really suspicious. I mean, it sounds as if the hospital administration is throwing itself on a grenade here…but you know, hospital administrators  are not usually the most altruistic of people. Hmmm….

First Bottom  Line:

Whoever dipped the syringe into the bowl, sucked up the chlorhexine, and passed it off as contrast is responsible. Period. Yes, I understand that it’s a bad coincidence and these things happen, but I would want to know the experience of the person who drew up that contrast and how much supervision was involved.  That is information that needs to be exposed.

In any event, I am going to get a bowl of chlohexidine and place it next to a bowl of contrast and see for myself if there isn't any noticeable difference in the texture, viscocity, feel and smell between the two substances.

I'm not saying I don'tunderstand how, after hours of tedious work in the angio suite someone could accidentally suck up the wrong colorless fluid and inject it into the catheter. I do. But that does not mean that the individual is not responsible for this action.

Second Bottom Line:

According to the Seattle Times, the Washington state Department of Health, says that Virginia Mason: 

had reported more "adverse events" over the past three years than three other Seattle hospitals —

Since the start of 2002, Virginia Mason, with 280 beds (licensed for 336), has reported nine adverse events, including four that resulted in the patient dying or being left in a permanent vegetative state,

During the same period, Swedish Medical Center, with 1,400 beds, reported four incidents and no deaths. Harborview Medical Center, licensed for 413 beds, reported five incidents including three that were catastrophic.

The University of Washington Medical Center, with 450 beds, reported seven incidents including three that were catastrophic

I can see why VMMC "has made a firm commitment to eliminate errors from our system entirely"

After Such Knowledge, What Forgiveness?

If VMMC really is serious about reducing their medical errors, coming clean, apologizing, and atoning for the death of Mary McClinton, here are the questions they need to answer NOW:

What did the original CT scan show?

Why was it decided to embolize Ms.McClinton's aneurysm?

Was the chlorhexine present on the procedure table from the beginning of procedure?

Was chlohexine used to wash off the groin before the original puncture?

Was chlohexine used to prep any other areas?

Was the bowl with chlohexine refilled during the arteriogram?

What volume bowls were used for the contrast and the chlorhexime?

What other bowls were on the table?

Were the embolization materials on a separate table from the contrast and disinfectant?

Who injected the contrast?

Was it a technologist?

Where was the catheter when the chlorhexime was injected?

Was chlorhexime injected into the leg (femoral artery) at the end of the exam? If so, why?

STAY TUNED

The solution used to clean skin before and after procedures was recently changed from a brown iodine-based solution to a colorless antiseptic, which looks exactly the same as the dye,

At some time during the procedure, the clear antiseptic solution was placed in an unlabeled cup identical to that used to hold the marker dye ... that is injected into blood vessels to make them visible on x-rays."

The antiseptic then was injected into a main artery carrying blood to the leg, 

The antiseptic solution is highly toxic when injected into a blood vessel. Acute and severe chemical injury to the blood vessels of the leg blocked blood flow to muscles, causing profound injury and swelling of the leg...Kidney failure, a sudden drop in blood pressure and a stroke followed.

The memo went on to describe the medical error as a "systems problem," where " no individual is responsible"

Thanksgiving: Rounds and Carnivals

Today's Thanksgiving Day treat: Two important blogosphere round-ups: First, shrinkette is hosting Grand Rounds, a weekly encapsulation of important posts throughout the medical weblog community (Doctor Mental hosts the compendium next week).

Next, head over to Interested-Participant (a good daily read to add to your bloglist) for this week's Carnival of The Vanities, which is a similar post of abstracts from some of the more intersting posts from around the blogosphere this week.

Boogieman Arrested In Utah For Alernative Medicine Murder

Boogieman Captured At Last

The Boogieman, otherwise known as a "practitioner of alternative medicine" was arrested in Utah for advising a woman with breast cancer to shun surgical and chemotherapeutic treatment. Instead, the Boggieman  convinced the woman to let him treat her metastatic breast cancer with chiropractic back cracking and some form of diet centered around "apricot kernels." Of course, this treatment regimen lead to her death and now Utah offials are peeved.

As a kid who cowered under the covers at night fearing a visit from the Boogieman, I am certainly glad to see him arrested with just punishment around the corner. However, I can tell you, there is not only one Boogieman. There are a gang of them out there, bigger than the Crips and Bloods put together.

Approach With Care... Boogiemen Use Spindust

Some boogiemen want to treat the flu with a homeopathic spindust (stuff that purports to "strengthen" the immune system) called  Oscillococcinum; others of the Boogie clan will crack your neck without indication, risking vertebral and carotid artery infarction among other bad outcomes.

Why do people allow these dark artists to hurt, maim and kill? That's a good question. We certainly chase after legitimate drug companies and doctors whom we suspect may have done something less than perfect in the pursuit of our health care; yet we are willing to buy prescription drugs through he mail, eat apricot kernels to treat breast cancer, treat the flu with fairy dust and let people crack our necks and backs...with no word said about the lack of effectiveness, or harm done by these Boogiemen.

Call 911

Will these Boogiemen eventually get arrested also? I hope so. If one of them approaches you to try and treat you, I suggest you dial 911. Maybe this will be the start of a trend and we could actually rid the world of ignorance and its disciples.

CSI MEDBLOGS: FRENCH ADMIT LYING ABOUT ARAFAT'S TEST RESULTS

The French are admitting that they lied about Arafat's test results, botched his care, failed to diagnose his disease, then watched the Arab leader die of complications that could have been averted.

French authorities have responded to this blog's relentless questioning regarding Yasser Arafat's test results.

______________________________________________________________________

CSI MEDBLOGS   STAT  SUMMARY OF THIS POST

                 (if you don't want to read it all):

AFTER THE SUMMARY, skip to the end and read TAKE HOME LESSON

_______________________________________________________________________

ONE:     The French now admit Arafat's Cat Scan of the abdomen was not normal

TWO:    The scan showed liver "nodules"

THREE:  They were afraid to biopsy the nodules because of Arafat's low platelets

WHAT THIS MEANS:

1. They lied about Arafat's test results (as this blog has been saying all along)

2. They saw lesions on the liver which they knew were either cancer  or   cirrhosis -- so they lied about Arafat absolutely not having "cancer"

3. If they nodules represented cirrhosis then there was no need to do a biopsy, so they either are incompetent and don't know how to read a CT scan

OR

4. They thought the nodules represented cancer, not cirrhosis. Then, they were afraid to do a diagnostic biopsy because of low platelets, but these types of biopsies are done all the time -- you just have to administer platelets right before doing the procedure -- so they failed to diagnose in a situation where diagnosis was possible

5. Because their incompetence and diagnostic timidity delayed diagnosis and treatment, Arafat developed a complication which lead to his death before any effective therapies could be initiated (they now admit Arafat developed a bleeding complication called DIC which probably lead to his brain bleed)

6. The entire charade thereafter -- the whole comatose cowboy routine -- was a stall and a cover-up while they tried to figure out what the hell to tell everyone

_________________________________________________________________________

     NOW FOR THE LONG VERSION:

AS STATED HERE THAT CT COULD NOT HAVE BEEN NORMAL

For weeks, CodeBlueBlog has been questioning the initial French report of a "normal" CT of the abdomen. As stated here many times, Arafat could NOT have end-stage liver disease and a normal CT.

Now, for the first time, the French are admitting they lied. Worse, the new revelations give a glimpse into just how bad their diagnostic and therapeutic skills are. I'm sure when the full records are reviewed the extent of the total incompetence and deceit will be staggering.

WHAT THE THUNDER SAID:     Datta. Dayadhvam. Damyata.

1. LIES

a. French medics saw significant findings on the CT  yet they said the CT  was normal

b. They also said Arafat did not have cancer, yet they admit they could not biopsy the liver nodules to rule cancer out

                                                                                                       

The CT was NOT normal. Now, according to Le Monde the French docs say that when they looked at the CT:      

                                                                     

"they saw nodules on the liver"

Oh, they did? Did they forget to mention those "nodules?" A minor point? NOT!

"Nodules" on the liver may  refer to the nodular contour of the peripheral liver edge noted on CT scan (see this post) which indicates the end-stage liver disease we've been talking about for so long.   

                                                

But let me say this: the French medics are not saying "nodular liver," they are saying "nodules." Nodules could be tumors. In the setting of cirrhosis, nodules could represent deadly liver cancer (same thing that Mickey Mantle had with his cirrhosis); but, if there were NO cirrhosis, then the nodules could be cancer spread from somewhere else (called metastases).

But the French said Arafat didn't have cancer, right? And they said there was NO CANCER on his CT scan.

2. INCOMPETENCE

But if there were nodules on the liver then the French can not know that Arafat didn't have cancer. And they PROVE that they saw the "nodules" and didn't know whether or not this represented cancer (thus completing a circular lie) when they told Le Monde again

"although they saw nodules on the liver, doctors did not reach a definitive diagnosis of cirrhosis because the platelet problem meant it was too dangerous to do a liver biopsy."

In essence the Saturday Night Live crew of physicians taking care of Arafat are saying that they saw the potential cancer but didn't want to do the test that would diagnose the cancer because the platelets were too low to do a biopsy.

Here's what this proves:

             

3. FAILURE TO DIAGNOSE

There is NO NEED to do a biopsy to diagnose cirrhosis -- I diagnose cirrhosis every day just by looking at the typical liver on CT -- I NEVER  do a biopsy.

If they say they had to do a biopsy then they are either INCOMPETENT or they suspected liver cancer or cancer spread from somewhere else (metastases).

Le Monde says that the French Docs did not want to do the biopsy they felt was necessary because they felt it was "too dangerous" to do a liver biopsy with Arafat's low platelets (this could cause bleeding)

I can tell you that I have done MANY invasive procedures, including liver biopsies, on patients with low platelets. When the biopsy is necessary, we just give the patient an infusion of platelets, then do the biopsy. A liver biopsy can also be done "internally" through a transjugular approach. Sacre Bleu! But this would be MODERN medicine, not the medieval stuff practiced in France.

4. DIAGNOSTIC DELAY--->COMPLICATION--->A TRIP TO COMA WORLD

So the French medics see an abnormality then they either don't recognize it for what it is OR they are wrongly afraid to do the diagnostic test needed. The proper diagnosis is delayed and Arafat develops a dreaded complication called DIC (disseminated intravascular coagulation), as again stated by Le Monde:

Le Monde cited “very good sources” as saying Arafat died of a blood disorder called disseminated intravascular coagulation, or DIC — where platelets are depleted by the formation of a multitude of microscopic blood clots all over the body and blood oozes easily from anywhere that’s vulnerable 

The DIC leads to Arafat's brain bleed (intracerebral hemorrhage) and then we have the famous slow descent into ever deeper States of Coma revealing the one thing the French doctors were good at: describing the slow demise of their patients. At least they are good at something.

My suggestion? Turn that hospital into a hospice, then the docs can do what they do as a service instead of providing calamity.

CodeBlueBlog's TAKE HOME LESSON:

Acute, high tech, sophisticated care is expensive -- REAL expensive. Countries with nationalized heal care don't feel that it is cost-effective to beef up high-tech, high-end care, especially on the community level. But in the United States, we put out the money and provide sophisticated, high-end care in almost every community. Icu-type care is the best, right here, in the United States.

Countries with nationalized health care do a real good job with the cheap stuff: handing out eyeglass prescriptions and taking care of your cold; but, when you or your loved ones wind up with a bad or sudden, severe problem that needs immediate, sophisticated, high-end care you better be in the U.S. because THAT'S when our health care system versus theirs makes a BIG difference.

The reason Canada and England and France have high patient satisfaction survey numbers is because 95% of people never need ICU- type care. Nationalized systems KNOW this. So they skimp on the tough stuff and give everyone pablum and everyone is happy. Until you REALLY need help.

Stay tuned.

I'll Have My Baby Over-Easy, Some Wheat Toast, Butter on The Side

No News Is...No News

Today's "news" is that more women are having C-sections...Oh, sorry, unnecessary C-sections, according to a British study due out November 20th. The "sharp" rise in C-sections is being called "dramatic"...hmmm...the sharp rise is a rise from 3.3 out of one hundred to 5.5 out of one hundred, and the dramatic increase is one that is documented over a 10 year period. Neither sharp nor dramatic, I'd say.

Weren't they calling this a problem in the 1980's, and the 1990's also? I guess there's a good publication in this topic like every ten years or so.

Someone should tell the British researchers that they can stop wasting their time looking for reasons ("It's not clear why this is taking place" they said). I'll tell them why.

I'll Be There Right After My Nail Appointment...

If they sort this out geographically they'll see that the rise in C-sections is surely centered around urban areas and it is likely due to two factors. First, many women today order their C-sections (i.e. they demand that the obstetrician peform a C-section rather than oversee a vaginal delivery) to be done at a time that is convenient for them. They schedule the procedure, just like they schedule their vacations. This is especially common with career women who need to plan the time off from work accurately. Besides, with a C-section women go into the hospital, get an epidural, then have the baby. No labor and delivery torture. 5 A.M. you're in the hospital, 7 A.M. you have your baby. I would find that attractive myself.

Torter Dens

Second, surely the threshold for doing a Cesarean gets lower all the time because of our friends the Torters. The British researchers looked at birth certificates of sectioned infants for labor and delivery complications that might indicate why a Cesarean was done, and did not find indications for many of theprocedures. The birth certificates? I'm not sure what the heck they were looking at but I know that there are many situations that are not going to be listed there -- subtle changes in late stage stress tests, ultrasounds, fetal heart rate, maternal conditions, etc, that present the obstetrician with the choice: play the odds, wait it out, and see what happens (with nightmarish visions of John Edwards channeling the baby to a jury) or do a C-section...hmmm...I think that RangelMD did a good job of correlating C-section rates in Texas with TC (Torter Concentration). Overlawyered.com has also covered the issue of repeat C-sections and their relationship to Tortology.

So, what's the value of this study? I give. Nothing we don't know; but check back in ten years, and someone will surely do it again.

Deconstructionism, Crock Pots, And Classical Values

Where The Pundit Sends You

Over at Classical Values, where I went chasing an Instapundit reference to the mystery of Arafat's death, I happened on a post that dovetails with my article earlier today on the power of the blogosphere as a a superheated evolutionary crock pot .

The author was waxing over the fluctuating value we attach to the word "truth" and the damage done to that concept as well as other ideals by the cataclysmic introduction of deconstructionism into the collegiate curriculum and then into modern intellectual circles...

One can consider deconstructionism as the intellectual equivalent of a computer "worm"  -- a mechanized, hidden, takeover of the CPU by an unseen cluster of commands that, without announcing itself, subsumes the computer's tasks for the purpose of propagating itself, or its own propaganda throughout its known universe.

Embarrassment of the Elites

This worm -- deconstructionism -- really is the underlying, resonant anthem of the modern European liberal -- the personage so cherished by the elites of this past election season -- the ones who've been so thoroughly embarrassed...

And part of that emabarrassment came about via the blogosphere, a phenomenon we've probably only just witnessed the birth of.

Here was my response to his post:

Escaping Gravity And Blasting Cytokines:

Yes, it is frustrating to try to find "truth" when faced with a host of responders ready to redefine the word -- or undefine the word or even your ability to talk about the concept. Your discussion is one I had with myself a long time ago and it is the reason I decided to pursue empirical science. Because you can't take that away from me. Because that's how rockets are made that can escape the pull of gravity and that's how monoclonal antibodies can be fashioned to obliterate subsectors of the inflammatory cascade and CURE rheumatoid arthitis...I'd rather pursue truths that can be tested and then used with confidence...and predictability.

But in the same fashion, I really, really believe that empirical truths exist in social sciences and in philosophy, except the proofs can always be disputed, and even when there are definable results they can be undermined by rhetoric (curse the Sophists who started it all); especially intellectually venal rhetoric that purposely (and deviously) appeals to common misunderstandings or lesser human ideals (such as greed).

Why The Blogosphere Matters...and Antimatters

The blogosphere holds out the first chance I've seen -- by its inborn evolutionary information processing -- to head off the massive antimatter-like deconstruction of everything once considered right that has been ongoing for 30 years -- the evil spawn of effete French philosophers.

If effective, and recognized, and adopted, the products of the "natural selection" of ideas from the blogosphere may produce the equivalent of empirical results so powerful and so indisputable as to create new ideals from which mankind can once again draw relevance and authority -- and that's why I've joined it.

Blogs Prove Theory of Evolution and Natural Selection

Reading back-and-forth posts between Amy Ritenour and Professor Bainbridge, I came across a Bainbridge post regarding the role of blogs. Recently the press has gone on the attack against the Sixth Estate (blogdom), portraying bloggers as drunken shoot-from-the hipsters or blind squirrels stumbling over acorns, and the like. You know what it's all about. The press is petulant that we're on to them and better than them. But why is the blogosphere so potent?

It's natural selection and evolution proved, real-time, every day.

SURVIVAL OF THE FITTEST

4 million blogs interconnected at the speed of broadband form a huge pool of selective forces -- a superheated evolutionary crock pot -- that in minutes and hours takes an idea and subjects it to the natural selective pressure of tens of thousands of minds filled with millions of ideas, experiences, facts and expertise.

In the history of humanity it takes millions of years for the selective pressures of the environment to coax changes out of the human organism. The adaptations selected for must increase the chances of survival, and this can only result in physiologic or morphological changes over the course of centuries and many generations.

In the blogosphere, this same scope of adaptive pressure -- forces applied by the scrutiny of tens of thousands of bloggers -- with varying levels of experience and expertise -- can occur in minutes and hours. So ideas and theories are immediately diffused and evaluated; and, just as in nature, 99.9% of what is proposed  becomes genetic litter; yet 0.1% of all propositions make the grade as significant and important items. And 0.1% of millions of items a year is probably enough positive reinforcement to create a whole new universe of ideas and beings. And that's what we are.

Gliding Lizard or Free Bird?

The Old Media cannot keep up. Its medium is outworn and its practitioners are complacent and arrogant; moreover, they are always fundamentally hamstrung by some owner's overarching ideological and monetary motivations. But these are the least of Old Media's competitive problems in a newly competitive universe. Old Media is fundamentally unable to match the massive assimilation and almost immediate selective scrutiny of data as occurs in the blogosphere. Thus Old Media represents that branch of evolution that produced gliding lizard-like pterodactyls whereas the blogosphere's divergence found light tubular bones and feathered wings as both attempt to fly into the future.