Wednesday, April 29, 2009

Conflicts of Interest

The ongoing inquiry into the events leading to Robert Dziekanski's death following tasering by the RCMP has provided a classic conflict of interest scenario:
A cardiology expert paid by the company that makes Tasers told a public inquiry Tuesday he doesn't think Robert Dziekanski's death was at all related to the controversial stun guns.

Dziekanski died on the floor of Vancouver's airport in the early morning of Oct. 14, 2007, minutes after four RCMP officers confronted him and stunned him several times with a Taser.

Dr. Charles Swerdlow, a cardiac electrophysiologist who receives compensation for sitting on Taser International's medical advisory board, appeared at the inquiry by video conference from California.

Swerdlow said if the Taser negatively affected Dziekanski's heart, it would happen almost immediately after he was stunned.

But he noted that an airport security guard has testified that he checked Dziekanski's pulse three times before firefighters arrived more than 10 minutes after his collapse. Trevor Enchelmaier told the inquiry that each time he checked, Dziekanski had a heartbeat.

"In Mr. Dziekanski's death, we know his [heart stopping] was not immediate, we know he had an adequate cardiac rhythm for a number of minutes following exposure to Taser," said Swerdlow, who works at Cedars-Sinai Medical Centre in Los Angeles and also teaches at the University of California.

"So nothing here fits with direct cardiac electrical stimulation."

Swerdlow also said that if the heart is affected by electrical current, the resulting heartbeat would be either too fast or irregular. The first time anyone noticed anything wrong with Dziekanski's heart was when firefighters arrived and found he had no pulse at all.
I gather that cross-examination of Dr Swerdlow has yet to occur, but I might ask him the following questions:
  • An airport security guard has testified that he was able to find Mr Dziekanski's pulse "three times" in the approximately ten minutes following his collapse prior to the arrival of the firefighters. Does evidence of a pulse in and of itself rule out arrhythmia or any other adverse effect potentially caused by multiple Taser "stuns"?
  • Did the security guard have adequate training or equipment (e.g. stethoscope, ECG leads) to ascertain Mr Dziekanski's condition?
  • What is the appropriate means of diagnosing an arrhythmia?
  • What level of electrical current would be sufficient adverse cardiac events or death? What are the causes of such results?
  • How do you know that Mr Dziekanski's cardiac rhythm was "adequate" in the period prior to his death and following the tasering? Were you present at the scene? If not, on what basis can you testify that his rhythm was "adequate"?
  • How much compensation do you receive from Taser International annually? Have you ever noted any examples of adverse cardiac events resulting from Taser use? Do you feel there is any conflict of interest in testifying in favour of the safety of a product whose manfacturer compensates you? Did you receive any additional compensation to appear at this inquiry? How often do you testify in Taser-related cases? Have you ever testified that the use of a Taser contributed to death or other adverse cardiac events?
I think that about covers it. I'd be very interested in the responses.

Saturday, April 18, 2009

Interview Time

Interview Weekend is once again upon us at Dal. Therefore, I present a music video that's almost as old as I am. For whatever reason, "Africa" by Toto has become some kind of thing song here. Enjoy.

Friday, April 10, 2009

Quacks in BC

"The regular docs treat the symptoms, whereas the naturopath tries to find the CAUSE."
So, they've done it. So-called naturopathic physicians will now be able to do the following:
  1. prescribe non-controlled medications (eg. they can prescribe Tylenol #3, all antibiotics, all mood altering medications - antidepressants, antipsychotics, mood stabilizers including lithium, immune suppressants such as prednisone, methotrexate), "after completing a certification training". A list of medications they cannot prescribe is attached at the end of the legislation (seems to be mainly narcotics / sedatives / chemotherapy agents)
  2. order Xrays / Ultrasounds (but no CTs)
  3. perform minor surgeries at or below dermis
  4. perform allergy challenge testing and desensitization
  5. insert finger/instrument/device into any body cavity, whether natural or artificially-created
Now, do naturopaths have the training for any of this, particularly minor surgery? For all their self-serving rhetoric, they do not have any hospital experience in their training, nor any mainstream medical exposure. No clerkship. No call. No residency. No OSCEs. Just dodgy self-regulation. And homeopathy.

Of course, I will not and cannot deny that many treatments in use today derive from natural sources. Digoxin, a very old drug used in heart failure, was isolated from Digitalis purpurea, a poisonous flowering plant also known as foxglove. That doesn't make homeopathy - a practice without any kind of rational pharmacological basis - a valid form of treatment, however, nor does it excuse the sort of rhetoric that seeks to set naturopathy apart from "allopathic" (i.e. mainstream) medicine:
  1. Vis medicatrix naturae: the body has the inherent capacity to heal in the proper therapeutic environment. NDs believe in the recuperative power of the organism, given the correct climate for healing. Determining the correct individualized therapeutic environment is at the core of naturopathic medicine.
  2. Tollum causum: remove the cause. Instead of treating the symptoms of disease the ND tries to cure the cause of the disease.
  3. Prima non nocere: do no harm. The ND is trained to use therapies that will not cause adverse side effects or cause secondary problems (i.e., iatrogenic disease) as serious or more serious than the original disease.
Regarding Vis medicatrix naturae, it's certainly true that the body has an inherent capacity to heal itself, but that "proper therapeutic environment" is absolutely key. For example, penicillin for a pharyngeal infection caused by Strep pyogenes is necessary to prevent secondary glomerulonephritis, the cause of which is related to the body's natural immune response to the bacteria. Untreated strep throat can also lead to rheumatic fever; proper treatment is certainly required. One wonders, then, what naturopaths think is unique about this principle.

The second principle is a frequent canard offered in support of naturopathy; that naturopaths treat the cause of disease rather than the symptoms, something that is supposedly the opposite of an MD's approach. This, of course, is simply non sequitur, which is not to say that purely symptomatic treatment is never warranted. On the other hand, naturopaths have a habit of inventing causes to explain a wide variety of non-specific symptoms:

Of course, Candida is everywhere and on you all the time. Most of the time it does nothing. To see what an actual bought of candidiasis looks like, simply Google "oral thrush". To see whether you might suffer from Candida "overgrowth", watch this video.

As for their last principle, "do no harm", it's nice to know that naturopaths have discovered the Hippocratic Oath. It's unfortunate, however, that they are under the delusion that adverse effects and problems secondary to treatments can be avoided. Since they seem mainly to cater to the worried well, however, most of their "treatments" are comparatively benign (if not entirely ineffective). I hope they behave responsibly enough to avoid going beyond their limited training and so avoid the aforementioned iatrogenic disease.

Wednesday, April 8, 2009

Reflections on a Consult Service

Since October I've been doing a first-year elective in Infectious Diseases. Mostly this entailed observing in the HIV clinic and on in-patient rounds in the QEII. Occasionally I'll get to listen to heart/lung/bowel sounds or help with history taking, though the latter typically only ever occurs in clinic. Initially, the plan had been to split my time equally between clinic and in-patient rounds, but the latter has ended up taking the lion's share of my time, something that I've liked.

Clinic is fairly non-threatening and low-key, and from the start I could appreciate the sorts of issues HIV patients face - side effects, compliance to meds, and all the psychosocial aspects unique to their situation. When I first went on in-patient rounds, I had to go meet the ID resident in Emerg where he was reviewing a consult. At this point, I could scarcely find my way around the hospital much less understand most of what I was hearing. As the afternoon progressed, I'd ask the odd question, but mostly I just listened, writing things down to look up later. I wrote down a lot.

As time went on, I met new residents coming onto the ID service more or less monthly. Everyone rotates through ID, and while most of the residents I've met have been in internal medicine, there have been others in physiatry, general surgery, neurosurgery, and ENT, along with a few actual ID fellows. I've really appreciated being able to meet so many people, to say nothing of the extremely varied patient exposure. I've been nearly everywhere at both sites of the QEII; ICUs, IMCU, Haem/Onc, CCU, MTU, Emerg, ENT, Ortho, Urology, various other clinics, and the dark, patient-less unit commonly known as Radiology. Even so, I still have only a vague sense of where many things are.

I'd say also that I've learned a lot about charts, how residents summarize patients for staff, and how a consult service works. I'm not sure whether I want necessarily to work on a service like ID in the end, but that's perhaps a topic for another post. In the end, I've enjoyed myself progressively more since January, both as I've learned more in class and as I've been lucky enough to end up with residents and staff who have been more open to teaching and having me listen and/or feel things for myself. This has really made all the difference. At this point, I can pretty much understand most of what the residents and staff are staying, and when I don't, I feel more confident and comfortable peppering them with questions. I know way more than I did in October, but the amount I don't know and have yet to learn always seems somewhat insurmountable.

I guess I'll get to that stuff eventually. My little assignment from today was to look up these:

Non-anion gap acidosis
Tumour lysis syndrome