Since 11-07-01
Since 11-07-01
From:
RMcphe8888@aol.com
Sent: Saturday, November 03, 2001 2:12 PM
Subject: From a non-Submarine "Doc" but well worth reading.
Richard McPherson
The
anthrax terrorism has allowed for the first time a direct comparison of
fresh Kaiser guidelines as contrasted to the (also fresh) Center for
Disease Control guidelines. The subtle manipulation for cost savings by
Kaiser in the Washington, DC area is rather amazing. But to double check
my editorialized comparisons for possible bias, any one can print out
these two relatively short documents.
The following is the Center for Disease Control's publication through the
national MMWR Weekly physician update. The date of this material is
November 2, 2001.
Click here: Update: Investigation of Bioterrorism-Related Anthrax and
Interim Guidelines for Clinical Evaluation of Persons Participants in
this document included C Chiriboga, MD, of the Southern MD Hospital,
Clinton, Maryland (where one of the two inhalation anthrax deaths occurred
after a patient was first sent home for the flu despite being a postal
worker and fainting in Church after a four day respiratory illness).
Another participants was S. Bresoff-Matcha, MD, Mid-Atlantic Permanente
Medical Group (which also contracts some care in the same hospital).
There were also many notable experts on the East Coast, so I believe this
document to be valid and representing good science from the CDC.
This next document may be found featured for physicians on the Kaiser
Permanente website - the only physician guideline I have found outside of
MD password protection, a website which I cannot even access despite being
listed as still on the staff of a Kaiser hospital. So the Kaiser
guideline is unique to itself but similar to care rationing as also to be
found in all of the other "best evidence" protocols that they use.
for a copy
of this anthrax guideline for physicians. The date of the Kaiser
"clinical guideline" is "revised October 28, 2001." As a Kaiser physician
was present in the CDC meeting and Kaiser's Washington, DC is one of the
leads Kaiser for quick communication among physicians, one would expect
the guidelines to match the CDC meeting within the same week. That is
ONLY if science matters.
But they do not exactly match. I will try to compare issues side by side
to see what happens when the art of medicine is downsized by the business
of medicine - even as our new heroes - the postal workers - and our
national leaders - are put at risk by the changes. Note that Kaiser is
non-profit (a pubic charity of sorts), while the Permanente medical group
is clearly for profit.
CDC
- this 12 page document begins with the classic review of cases so that
physicians can get oriented with clinical histories of disease among the
various cases state to state. Reveals that the first chest x-ray on the
postal worker near Washington, DC was read incorrectly by the ER doc as a
normal chest mediastinal appearance, and the patient was sent home. After
a good discussion options, there is a statement on page 8 that starting
with doxycycline may be preferable not so much for the patient
[(Hippocratic ethic of best care for patient) but for the prevention of
resistant organisms occurring with Cipro (the public health - distributive
ethic of risking the individual for society's benefit)].
Kaiser
-
this 7 page document begins with the idea that potentially exposed
patients can be switched from Cipro to the much cheaper Doxycycline after
10 days. Encourages patients to tell their doctors if they "are having
difficulty tolerating Cipro" [hint to physician]. Patients getting Cipro
from the government ("screening site") should go back there for refills
[thus staying off Kaiser's budget]. The focus is to cut sudden Cipro
costs, as Kaiser's back in the black on 2001 budget; but hospitalizations
and pharmacy costs always risk Kaiser's budgets.
CDC
- nasal swabs are mostly useful for checking exposure patterns among
groups to discover disease drift into the population.
Kaiser
- "Nasal swabs are no longer recommended, per Mid-Atlantic Permanente
Medical Group infectious disease specialists and based on conversations
with CDC." This is written in bold on the first page of the Kaiser
"guideline"!!! [Whose conversations with who in CDC? Health plans
including Kaiser on the East Coast - acting lockstep as always - are
trying not to pay for nasal swabs even though it might catch the spread of
these diseases among postal workers and the public.]
CDC
-
watch out for those with "fever with or without chills, sweats (often
drenching), fatigue, malaise, cough (usually nonproductive), shortness of
breath, chest discomfort, pleuritic pain, nausea, vomiting, diarrhea,
abdominal pain, headache, myalgias, sore throat, and fever." Order tests.
If a chest x-ray is normal, consider a computerized tomography exam (CT
Scan) of the chest. "Notify public health" of the suspect case (anthrax
is a phone call reportable disease even when you just suspect it - meaning
lots of calls).
Kaiser
- "If
the patient is symptomatic (headache, profuse sweating, achiness, fever,
coughing, chest pain, and/or difficulty breathing) and unstable:" then
order tests, give Cipro and send to ER. But if the patient is "stable" by
9-1-1 criteria and chest x-ray normal, the patient can go home on Cipro or
doxycycline!!! [If you are a Kaiser physician, that means doxycycline -
your pharmacy utilization is displayed to others at the monthly meeting.]
There is no notification of public health mentioned for these cases. [So
the postal worker who was sent home only to come back and die - in a
Kaiser contracted hospital - would now upon reappearing at a Kaiser
Washington, DC facility most likely be sent home once again - this time on
doxycycline rather than being admitted and put on triple therapy. Kaiser
is bragging about using the standard triple medications for the admitted
inhalation anthrax; the question is Who is being sent home and not treated
correctly!]
CDC
- once the chest is cleared - perhaps by a CT Scan - and other tests are
okay, the patient might go home. But the physicians must "observe closely"
for new symptoms. [To a physician that means daily followup with a call
of visit in an illness that progresses as fast as this one.]
Kaiser
- "Follow-up should be assured either through an appointment or a phone
call with the primary care physician/health care team," [Kaiser has since
1997 tried to move patient care over to health care teams (FNP/RN/clerk/etc.)
to decrease costs as part of their Path to Recovery - 2001.] This is not
close followup. Even physicians are on a sharp learning curve for this
illness.
CDC
- if patient is even "moderately ...ill," do more aggressive testing and
begin serious antibiotic treatment. Oxygen level is not even mentioned.
Kaiser
- if the patient is less than 9-1-1 unstable [confused, shocky, low O2],
then one does not have to get serious. Then Kaiser adds pulse oximetry to
check oxygen level as a way to prove patients are too well to be admitted.
[This is pre-anthrax thinking of M&R utilization review cookbook level -
since anthrax moves through the lungs quickly to destroy the central lymph
nodes and spleen; thus low oxygen is not a valid screening out test for
this problem.]
CDC
- for suspicious skin lesions, the physician should unroof the skin lesion
(even consider a skin biopsy), get blood cultures, start medication, and
notify public health.
Kaiser
- the only mention of skin lesions is on those who have come in with
severe respiratory symptoms and are "unstable." [Why clog up expensive
HMO ERs or derm clinics looking for anthrax?] Let all this fall to
"designated treatment/testing sites" [like the impoverished and
overcrowded Washington, DC public hospitals, so that the problem will fall
to public health, work comp, city, or general tax budgets].
CDC
- no mention that postal customers are safe. Clearly visitors to
contaminated media areas have gotten Anthrax. [And the anthrax spores
went a far distance from Senator Tom Daschle's office around the
building.]
Kaiser
-
"NOTE: Customer postal access areas are not considered at risk" This
statement is made twice in the 7 page document. [No source for this but it
sure saves a lot of testing; the usual Kaiser approach to a simple cough
is a telephone advice nurse suggesting a cold pack.] There is even Kaiser
advice nurse guidelines which suggest to focus only on those with obvious
exposure and significant symptoms.
CDC
-
high alert for those in known anthrax risk facilities like Brentwood;
Kaiser
- only if the patient is "unstable by 9-1-1 criteria" (underlined/bold)
should they go to ERs [MD Salaries $100/hour]; instead you have "3 hours"
to send them to clinics [MD Salaries $60/hour]. Even if you are congested
and have a sore throat among the Brentwood postal service, you can wait
"12 hours" to be seen. [But anthrax is one of those illnesses that kills
quickly.]
CDC
- "Public health response must include prompt initiation of prophylaxis
for exposed persons and systems to promote adherence to a full 60-day
regimen" (page 8)
Kaiser
-
"Final recommendations for the length of prophylactic antibiotic therapy
is pending at this time." [Pending where? Perhaps above Lake Merritt in
Oakland at Dr. David McKinnon Lawrence's desk as CEO and business rock
star? I would have thought as a member of the National Academy of
Science, he might want the patient to get the best scientific treatment
until proved otherwise.]
As a physician in practice for 32 years and living on the West Coast in
Kaiser-fornia, I am disgusted to see science hijacked at the risk of front
line postal workers on the East Coast. (And Kaiser has done the same with
all of their 'best evidence" guidelines thus hurting many pregnant women,
diabetics, heart patients, etc.) In a way this hijack of anthrax science
puts us all at risk across the great country because we will have stay on
the receiving end of this terrorist epidemic until we get our medical act
together.
Charles Phillips, MD,
Board Certified Emergency Physician
Fresno, California - 559-431-4754
(a civilian war detox expert - 1991 - Gulf War)
PS - I hope the East Coast postal unions see this posting before it is too
late. So any one may repost this message and media may use it. I take
full responsibility for all of my comments. Perhaps the best way to
combat Homeland terror would be to pass the McCain Patients Bill of
Rights, and the sooner the better to avoid poor HMO responses to this
crisis. A $10 million reward for finding the
source of the anthrax would not hurt either. That
would be cost effective!