trauma-list Digest, Vol 76, Issue 18

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Nurse practitioners already have limited prescribing 
rights in the UK

On Thu, 15 Oct 2009 05:09:14 +0100
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> Today's Topics:
> 
>   1. Re: Michigan 3% tax on doctors and PAs 
>(KMATTOX at aol.com)
>   2. Re: Michigan 3% tax on doctors and PAs 
>(Krin135 at aol.com)
>   3. RE: Excess Radiation from CT of concern at LA 
>Hospital
>      (Pret Bjorn)
>   4. Re: Excess Radiation from CT of concern at LA 
>Hospital
>      (KMATTOX at aol.com)
>   5. Re: Excess Radiation from CT of concern at LA 
>Hospital
>      (KMATTOX at aol.com)
>   6. RE: Excess Radiation from CT of concern at LA 
>Hospital
>      (McSwain, Norman E Jr.)
>   7. Re: Excess Radiation from CT of concern at LA 
>Hospital
>      (KMATTOX at aol.com)
>   8. RE: Recognition for (Peace) Performance (Vic 
>Werlhof)
> 
> 
> ----------------------------------------------------------------------
> 
> Message: 1
> Date: Wed, 14 Oct 2009 21:58:19 EDT
>From: KMATTOX at aol.com
> Subject: Re: Michigan 3% tax on doctors and PAs
> To: trauma-list at trauma.org
> Message-ID: <c26.684d9567.3807dbbb at aol.com>
> Content-Type: text/plain; charset="US-ASCII"
> 
> Does this mean that Michigan will give Nurse 
>Practioneers independent  
> practice credentials and prescription writing?     
> 
> k
> 
> 
> 
> 
> In a message dated 10/14/2009 8:50:56 P.M. Central 
>Daylight Time,  
> Krin135 at aol.com writes:
> 
> since  the PAs may be leaving as fast, I guess that 
>means that there will 
> be 
> a  growth in Nurse Pracs (if they are not covered by the 
> law).
> 
> ck
> 
> 
> 
> 
> 
> ------------------------------
> 
> Message: 2
> Date: Wed, 14 Oct 2009 22:05:17 EDT
>From: Krin135 at aol.com
> Subject: Re: Michigan 3% tax on doctors and PAs
> To: trauma-list at trauma.org
> Message-ID: <cff.621d6d8a.3807dd5d at aol.com>
> Content-Type: text/plain; charset="US-ASCII"
> 
> I'm not sure about Michigan, but several other states, 
>including Louisiana, 
> Illinois and Missouri have limited independent 
>prescribing authority for 
> NPs and  collaborative practice agreements rather than 
>subordinate practice 
> agreements.  The US DoD system allows them even more 
>liberal practice 
> standards.
> 
> Not sure about other states, but my understanding is 
>that collaborative  
> practice and at least limited prescribing authority is 
>pretty much the  norm.
> 
> ck
> 
> 
> In a message dated 10/14/2009 19:58:49 Central Standard 
>Time,  
> KMATTOX at aol.com writes:
> 
> Does  this mean that Michigan will give Nurse 
>Practioneers independent   
> practice credentials and prescription writing?      
> 
> k
> 
> 
> 
> 
> In a message dated 10/14/2009 8:50:56 P.M.  Central 
>Daylight Time,  
> Krin135 at aol.com writes:
> 
> since   the PAs may be leaving as fast, I guess that 
>means that there will 
> be  
> a  growth in Nurse Pracs (if they are not covered by the 
>  law).
> 
> ck
> 
> 
> 
> --
> trauma-list : TRAUMA.ORG
> To change  your settings or unsubscribe  visit:
> http://www.trauma.org/index.php?/community/
> 
> 
> 
> 
> ------------------------------
> 
> Message: 3
> Date: Wed, 14 Oct 2009 22:25:20 -0400
>From: "Pret Bjorn" <p.bjorn at tds.net>
> Subject: RE: Excess Radiation from CT of concern at LA 
>Hospital
> To: "'Trauma-List [TRAUMA.ORG]'" 
><trauma-list at trauma.org>
> Message-ID: 
><4ad68812.48c3f10a.1c5b.ffffef94 at mx.google.com>
> Content-Type: text/plain;	charset="us-ascii"
> 
> 1: I don't disagree with you about over-utilization of 
>diagnostic test in
> general and imaging in particular.  I just think that 
>using the Cedars mess
> to fuel these assertions is a bizarre stretch.  The 
>Cedars cases were a
> matter of procedural technique, not diagnostic process. 
> If you're going to
> play fast and loose with the evidentiary nexus, why 
>didn't you just blame
> Chernobyl and save us 20 years of irresponsible 
>scanning?
> 
> 2: Your first case of radiation-related ALL was probably 
>a very long time
> ago.  It's been a quarter-century since my brother died 
>of the disease; but
> even then we knew that radiation was by far the leading 
>causative culprit in
> adults.  There's no news there.
> 
> 3: "Some persons were concerned that I shared this 
>investigation with you."
> Please.  This is more FDA than FBI.  You're safe from 
>reprisal.  And I
> expect that your radiology department is probably able 
>and eager to
> formulate its response without any help from the trauma 
>service.
> 
> Let's see if we might all calm down a bit.
> 
> Pret
> 
> -----Original Message-----
>From: trauma-list-bounces at trauma.org 
>[mailto:trauma-list-bounces at trauma.org]
> On Behalf Of KMATTOX at aol.com
> Sent: Wednesday, October 14, 2009 8:34 PM
> To: trauma-list at trauma.org
> Subject: Excess Radiation from CT of concern at LA 
>Hospital
> 
> 
> 
> ... There is NO question that far too many CTs are being 
>ordered.   There is
> NO question that many physicians who order  CTs only 
>review the reports and
> not the actual image.   There is NO  question that many 
>over readings and
> terminology to cover ones backside are  often cited on 
>many images.   There
> is NO question that initial  readings are frequently 
>are-written after
> further review and the original  dictation mysteriously 
>disappears.    There
> is NO question that  many VOMITs are being dictated as I 
>am aware of many
> cases where operations were  not performed because of 
>the CT reading in
> patients who needed an operation and  likewise 
>operations were performed on
> the basis of the CT, when no pathology at  all was found 
>at surgery.
> We have already  had our first case of lymphoblastic 
>leukemia in a 
> patient with significant  radiation dosage from CTs, 
>arteriograms, and other
> 
> imaging.     
> Some persons were concerned that I shared this 
>investigation with  you.   I 
> am aware that regulatory agencies have alerted their 
>field  representatives 
> to specifically look at the dosing from CTs and the 
>record  keeping.    I 
> will repeat, "A word to the  wise.....".     Each of us 
>will be asked to
> show that we are  monitoring the dosing from imaging 
>from CTs, IR, and other
> 
> arteriography  etc.     
> 
> If you think that this story out of California is 
>trivial, just  check with 
> your Radiation Safety Officer.   
> 
> k
> 
> 
> 
> ------------------------------
> 
> Message: 4
> Date: Wed, 14 Oct 2009 22:29:32 EDT
>From: KMATTOX at aol.com
> Subject: Re: Excess Radiation from CT of concern at LA 
>Hospital
> To: trauma-list at trauma.org
> Message-ID: <cdd.5bce32ab.3807e30c at aol.com>
> Content-Type: text/plain; charset="US-ASCII"
> 
> It was last year.     
> 
> k
> 
> 
> In a message dated 10/14/2009 9:26:02 P.M. Central 
>Daylight Time,  
> p.bjorn at tds.net writes:
> 
> 2: Your  first case of radiation-related ALL was 
>probably a very long  time
> ago. 
> 
> 
> 
> ------------------------------
> 
> Message: 5
> Date: Wed, 14 Oct 2009 22:31:41 EDT
>From: KMATTOX at aol.com
> Subject: Re: Excess Radiation from CT of concern at LA 
>Hospital
> To: trauma-list at trauma.org
> Message-ID: <c80.5d007581.3807e38d at aol.com>
> Content-Type: text/plain; charset="US-ASCII"
> 
> Nope,   it is not they that order the tests.   The 
> doctors that 
> indiscriminately order CTs and IR are liable, especially 
>if they do  not even LOOK at 
> the images they order.      
> 
> k
> 
> 
> 
> 
> In a message dated 10/14/2009 9:26:02 P.M. Central 
>Daylight Time,  
> p.bjorn at tds.net writes:
> 
> And I
> expect that your radiology department is probably able 
>and eager  to
> formulate its response without any help from the trauma 
> service.
> 
> 
> 
> 
> ------------------------------
> 
> Message: 6
> Date: Wed, 14 Oct 2009 21:45:51 -0500
>From: "McSwain, Norman E Jr." <nmcswai at tulane.edu>
> Subject: RE: Excess Radiation from CT of concern at LA 
>Hospital
> To: "Trauma-List [TRAUMA.ORG]" <trauma-list at trauma.org>
> Message-ID:
> 	<B79C02DCC4FA074DB02381DF1C5D60BA01D2899B at EX07.ad.tulane.edu>
> Content-Type: text/plain; charset="iso-8859-1"
> 
> I agree with what Ken has said about over ordering of 
>CT's an other studies; providers looking only at the 
>reports and not actually viewing the images themselves; 
>management decisions being made by a non clinician 
>(radiologist) without cross checking the images by the 
>clinician; routine ordering or CT (and other tests) on 
>trauma patients; and lack of proper documentation of the 
>need of a procedure. I pointed this out on a recent 
>posting of the fight that had to prevent the non surgical 
>clinicians when I did not want to order a CT on a gunshot 
>chest when the management was obvious on a plain 
>radiograph.
> 
> I expect that most of the readers of this list serve 
>have many examples of all the items listed above. If we 
>are aware of those -- so are the regulators. It will not 
>be long before the trauma verification committee, JCAHO, 
>CMS and others will began to check these on their visits 
>to our institutions. We had  better be prepared and start 
>to look for solutions of these oversights now. But more 
>importantly, we MUST protect our patients and provide 
>them with proper care not VOMIT.
> 
> Norman
> 
> Norman McSwain MD
> Trauma Director, Charity Hospital
> Professor of Surgery, Tulane University
> New Orleans LA
> 504 988 5111
> norman.mcswain at tulane.edu 
><mailto:norman.mcswain at tulane.edu> 
> 
> ________________________________
> 
>From: trauma-list-bounces at trauma.org on behalf of 
>KMATTOX at aol.com
> Sent: Wed 10/14/2009 7:34 PM
> To: trauma-list at trauma.org
> Subject: Excess Radiation from CT of concern at LA 
>Hospital
> 
> 
> 
> 
> 
> 
> The story below was released on CNN  yesterday.     I 
>was with a doctor
> from the specific  hospital under investigation later in 
>the day and the story
> was  confirmed.    I have confirmed the story now from 
>at least 5  sources. 
> The exposure was up to 8 times the recommended dose for 
>the  condition for
> which the CTs were being ordered.    This is a  matter 
>of the technician
> and supervising radiologist making the appropriate 
> calculations and
> oversight.     There but for the grace of  God are all 
>of us.      I did ask
> radiologist and  radiation safety officers just how 
>often this kind of over
> calculation might  actually happen.   I will not quote 
>what I was told, but this is
> NOT a  fickle issue.    There is NO question that far 
>too many CTs are 
> being ordered.   There is NO question that many 
>physicians who order  CTs only
> review the reports and not the actual image.   There is 
>NO  question that
> many over readings and terminology to cover ones 
>backside are  often cited on
> many images.   There is NO question that initial 
> readings are frequently
> re-written after further review and the original 
> dictation mysteriously
> disappears.    There is NO question that  many VOMITs 
>are being dictated as I am
> aware of many cases where operations were  not performed 
>because of the CT
> reading in patients who needed an operation and 
> likewise operations were
> performed on the basis of the CT, when no pathology at 
> all was found at
> surgery.       We have already  had our first case of 
>lymphoblastic leukemia in a
> patient with significant  radiation dosage from CTs, 
>arteriograms, and other 
> imaging.    
> Some persons were concerned that I shared this 
>investigation with  you.   I
> am aware that regulatory agencies have alerted their 
>field  representatives
> to specifically look at the dosing from CTs and the 
>record  keeping.    I
> will repeat, "A word to the  wise.....".     Each of us 
>will be asked to show
> that we are  monitoring the dosing from imaging from 
>CTs, IR, and other
> arteriography  etc.    
> 
> If you think that this story out of California is 
>trivial, just  check with
> your Radiation Safety Officer.  
> 
> k
> 
> Radiation Overdoses At Cedars-Sinai Prompt Investigation
> 
> 
> 1:57 pm 
> October 14, 2009 
> _comments  (0)_
> (http://www.npr.org/blogs/health/2009/10/cedars_sinai_ge_found_to_be_be_1.html#commentBlock) 
> _Recommend (6)_ (javascript: 
>NPR.community.recommendStory();)
> 
> byline goes here
> 
> By Maggie Mertens
> Only after a patient complained in August about losing 
>some hair following
> a  CT scan did Cedars-Sinai Medical Center realize more 
>than 200 people had
> been  exposed to excessive radiation from diagnostic 
>tests performed there
> in the last  year and a half. 
> 
> 
> Cedars-Sinai Medical Center in Los Angeles, where more 
>than 200 patients
> were  exposed patients to excess radiation during CT 
>scans. (Ric  Francis/AP)
> 
> We first heard about the problem, involving doses  as 
>much as eight times
> normal, when the Food and Drug Administration issued a 
>_cryptic  warning to
> hospitals_ 
>(http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices
> /ucm185898.htm)  last week, urging them to be on guard 
>for excessive  radiation
> doses from CT scans for stroke. 
> But the advisory didn't name the hospital or maker of 
>the scanner involved.
> General Electric made the scanner, we later learned. 
> Now we know those details, but we still don't have a 
>definitive answer on
> how  a scanner being used to diagnose strokes delivered 
>enough radiation to
> redden  skin and cause hair loss in some patients. The 
>FDA told us today that
> it's  continuing to investigate both user errors and the 
>scanner itself. 
> So far it looks as if the CT scanner operators at 
> Cedars-Sinai failed to
> heed notices of jacked-up radiation doses after 
> technicians reprogrammed the
> machine and overrode standard settings, the Los  Angeles 
>Times _reported_
> (http://www.latimes.com/news/local/la-me-cedars-sinai14-2009oct14,0,5065886.st
> ory?page=2) .  The overdoses carried a 1-in-600 lifetime 
>risk for causing a
> brain tumor,  according to an outside doctor's 
>calculation cited by the
> paper.
>For its part, Cedars-Sinai says it has put in place 
>double-checks to make 
> sure the problem doesn't happen again. And the hospital 
>continues to probe
> how  the situation persisted for 18 months unnoticed.
> GE has stated the excess radiation wasn't its fault. 
>"There were no 
> malfunctions or defects in any of the GE Healthcare 
>equipment involved in the 
> incident," they told us in a statement.
> Back in August we _reported  how more and more people_
> (http://www.npr.org/blogs/health/2009/08/heart_stress_tests_pump_up_rad.html) 
> are being exposed
> to high doses of radiation  through common medical 
>tests, even when
> performed properly. If you're concerned  about radiation 
>from scans, talk over the
> risks and benefits of the tests with  your doctor.
> categories: _Hospitals_ 
>(http://www.npr.org/blogs/health/hospitals/) 
> 
> October 14, 2009
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> 
> Cedars-Sinai Under Investigation for CT Radiation 
> Overexposure to 206
> Patients
> 
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> 
> Cheryl Clark, for HealthLeaders Media, October 12,  2009
> 
> The 206 people who received "significant" overdoses of 
>radiation eight
> times  above expected levels were undergoing CT scans 
>for detection of stroke at
> Cedars  -Sinai Medical Center in Los Angeles, federal 
>and hospital
> officials confirmed  on Friday.
> 
> The incidents, which may have occurred over an 18-month 
>period starting in 
>February 2008, is under investigation by California 
>public health officials
> and  the U.S. Food and Drug Administration.
> The multi-slice CT scanner involved was manufactured by 
>GE Health Care,
> said  Mary Long, spokewoman for the FDA. "We are 
>evaluating information to
> determine  if this is a more widespread problem with CT 
>protocols and not
> limited to one  facility or scan," she said. The FDA 
>wants hospitals that may have
> had similar  problems with such scans to file a 
>voluntary report to the
> agency's _Medwatch Web site_
> (http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm185898.htm) 
>.
> "We are collecting information from the manufacturer and 
>the facility 
> relating to both the equipment and its use," she added.
> Sandy Van, spokesman for Cedars-Sinai, said the problem 
>was noticed in
> August  2009, "when a patient who had previously 
>received a scan contacted the
> medical  center after noticing temporary patchy hair 
>loss.
> "Since this is not a common side-effect from CT brain 
>perfusion scans, 
> Cedars- Sinai immediately began an investigation of the 
>equipment involved and 
> the protocols used for CT brain perfusion scans," Van 
>said in a statement.
> "No  additional CT brain perfusion scans were done until 
>the investigation
> was  completed."
> Van did not answer a question about how many patients 
>had experienced 
> symptoms linked with radiation overdose, but according 
>to a Los Angeles  Times
> article on Saturday, a hospital spokesman said about 40% 
>of the  patients
> lost patches of hair as a result of the overdoses. It is 
>unclear why  the
> problem with the scans was not recognized until August.
> GE Healthcare said in a statement "there were no 
>malfunctions or defects in
> any of the GE Healthcare equipment involved in the 
>incident."
> They emphasized that "patients and families should 
>continue to have 
> confidence in their doctor's recommendation for a CT 
>scan."
> Also, the company said GE "continues to offer 
>dose-reducing technologies
> and  expand key CT training initiatives to raise 
>awareness of dose
> optimization and  use of appropriate exam protocols.
> "GE Healthcare CT products require that: 1) users 
>carefully evaluate 
> user-defined scanning protocols against the validated 
>protocols that are 
> provided on the scanners during installation, 2) like 
>dose recommendations for 
> drugs, the recommended dose for a prescribed medical 
>imaging scan is an 
> important clinical decision that should be made by a 
>licensed professional in  the
> context of healthcare delivery."
> The investigation revealed that some scans "were 
>delivering a higher dose
> of  radiation than anticipated, which could cause 
>temporary hair-loss or 
> skin-reddening in some patients," Van said.
> 
> 1  | _2_
> (http://www.healthleadersmedia.com/content/240317/page/2/topic/WS_HLM2_TEC/CedarsSinai-Under-Investigation-for-CT-Radiation-Overexposure-to-206
> -Patients.html) 
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> 
> 
> _More  People Are Living With, Not Dying From, Hip 
>Fractures_
> (http://www.healthleadersmedia.com/content_redirect.cfm?content_id=240474) 
> 
>First, the good news. The percentage of the population 
> suffering hip
> fractures has declined and fewer people are dying from 
>them. Now,  the bad news.
> Patients who do fracture their hip and live to tell 
>about it...
> 
> Web Exclusive: _Sleepy  Surgeons Cause More Errors Than 
>Well-Rested Docs_
> (http://www.healthleadersmedia.com/content_redirect.cfm?content_id=240473) 
> 
> Hospitals seeking to reduce their operative complication 
> rates should make
> sure their attending surgeons get at least six hours of 
>sleep  between the
> time they last performed an operation, according to a 
>study.
> 
> _Cedars-Sinai  radiation overdoses went unseen at 
>several points_
> (http://www.healthleadersmedia.com/content_redirect.cfm?content_id=240469) 
> 
> Beginning in February 2008, each time a patient at 
> Cedars-Sinai Medical
> Center in Los Angeles received a CT brain perfusion 
>scan,  the dose displayed
> would have been eight times higher than normal. No...
> 
> Book: _National Patient Safety Goals Calculator 2009_
> (http://www.hcmarketplace.com/prod.cfm?id=6608&s=EHLM)  
> The National Patient Safety Goals Calculator, 2009:Tools 
> to Assess
> Compliance is a series of highly interactive tools that 
>bring  department leaders
> and staff into the compliance assessment...
> 
> _go  to complete list_
> (http://www.healthleadersmedia.com/related/240317/topic/WS_HLM2_TEC/CedarsSinai-Under-Investigation-for-CT-Radiation-Overexposure
> -to-206-Patients.html)  
> 
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> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
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> 
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> 
> ------------------------------
> 
> Message: 7
> Date: Wed, 14 Oct 2009 23:09:00 EDT
>From: KMATTOX at aol.com
> Subject: Re: Excess Radiation from CT of concern at LA 
>Hospital
> To: trauma-list at trauma.org
> Message-ID: <bd4.51df092f.3807ec4c at aol.com>
> Content-Type: text/plain; charset="US-ASCII"
> 
> .......................and so do the lawyers.   They are 
>already  having 
> seminars giving them all of the details on how to sue 
>the surgeons,  emergency 
> physicians, nurse practioneers, neurosurgeons, 
>hospitalists, and  
> radiologists, for the CT related complications and 
>diseases which we have caused  
> because we have not disciplined ourselves.     
> 
> k
> 
> 
> 
> 
> 
> 
> In a message dated 10/14/2009 9:46:48 P.M. Central 
>Daylight Time,  
> nmcswai at tulane.edu writes:
> 
> I expect  that most of the readers of this list serve 
>have many examples of 
> all the  items listed above. If we are aware of those -- 
>so are the  
> regulators.
> 
> 
> 
> ------------------------------
> 
> Message: 8
> Date: Wed, 14 Oct 2009 21:09:00 -0700
>From: "Vic Werlhof" <werlhof at gmail.com>
> Subject: RE: Recognition for (Peace) Performance
> To: "'Trauma-List [TRAUMA.ORG]'" 
><trauma-list at trauma.org>
> Message-ID: <00eb01ca4d4d$3aaf2da0$b00d88e0$@com>
> Content-Type: text/plain; charset="us-ascii"
> 
> 
> 
> 
> 
> -----Original Message-----
>From: trauma-list-bounces at trauma.org 
>[mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Pret Bjorn
> Sent: Wednesday, October 14, 2009 3:18 AM
> To: 'Trauma-List [TRAUMA.ORG]'
> Subject: RE: Recognition for (Peace) Performance
> 
> 
> 
> Please: cite a more demonstrable shift in American 
>foreign policy objectives
> 
> since World War II.  Saturday Night Live* actually 
>nailed it: Obama won
> 
> chiefly for not being George W. Bush.  The differences 
>were like black and
> 
> white. - Uh, is that a racist comment?
> 
> 
> 
> 
> 
> Still haven't answered my question: who did MORE in 2008 
>than Obama? - More
> what?
> 
> 
> 
> 
> 
> *Hey, if Vic can cite NewsMax, I can cite SNL. - Cite 
>whatever you want.
> 
> 
> 
> cid:3608CFC43EC640F7BB3EEAA41D0FBCFA at Robs
> 
> 
> 
> Vic
> 
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> ------------------------------
> 
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> End of trauma-list Digest, Vol 76, Issue 18
> *******************************************

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