Category: Essays

“A good gulp of hot whisky at bedtime—it’s not very scientific, but it helps.”
– Alexander Fleming

The practice of medicine demands that a doctor give the best possible care without knowingly causing the patient harm. A physician is supposed to have the well-being of his or her patients as the paramount issue of his or her practice. This position in the doctor’s hierarchy of care is never supposed to be affected by money, fame, glory or power. Yet, as the following story illustrates, doctors are only human and are swayed by money.
Until about the early 1940s, alcohol-containing beverages were seen as having medicinal properties. As far back as in ancient China, Egypt, Greece and Rome, healers treated everything from snake bites to pain with booze. Alcohol was recognized for it’s antiseptic and analgesic properties. Even during the American Civil War, field medics used whiskey and brandy to treat pain when they ran out of opiates. At the beginning of the 20th century, whiskey was being used to treat delirium, anemia, dyspepsia and snake bites. A common adult dose was about 1 ounce every 2-3 hours. Child doses ranged from 1/2 to 2 teaspoons every three hour. In some cases, alcohol could comprise as much as 40% of a patient’s daily intake!
Even today, we still hear of remedies like
rubbing a teething infant’s gum with whisky or drinking hot beer to treat the common cold.
Around 1850, scientific medicine started emerging in the US. With that, the therapeutic benefit of alcoholic beverages started to be questioned. By the early part of the 20th century, this anti-alcohol-for-medicine movement had gained traction. It also coincided with the Prohibition movement.
In 1916 whiskey and brandy were removed from the list of scientifically approved medicines in The Pharmacopeia of the United States of America.
In June 1917, even as the 18th Amendment to ban alcohol was slowly working it’s way through Congress, the American Medical Association (the AMA) voted to denounce the use of alcohol for medical purposes.
The resolution read:
Whereas, We believe that the use of alcohol is detrimental to the human economy and,
Whereas, its use in therapeutics as a tonic or stimulant or for food has no scientific value; therefore,
Be it Resolved, That the American Medical Association is opposed to the use of alcohol as a beverage; and
Be it Further Resolved, That the use of alcohol as a therapeutic agent should be further discouraged.
In 1920, Congress passed the 18th Amendment and with the Volstead Act, Prohibition was ushered in. However, the law allowed the use of alcoholic beverages (beer, wines, whiskey and brandy) for medicinal purposes and for the Holy Sacrament. I guess the cultural use of alcohol as a drug was too strong.
The next few years saw the prescriptions of alcohol skyrocket. Using prescription pads obtained from the Treasury Department, doctors could sell patients prescriptions for a pint of whiskey every 10 days for $3 ($40 today). For $3 more, a pharmacist would then fill it.
In Chicago, a pharmacist named Charles Walgreen grew his chain of 20 stores in 1920 to 525 in 1930 through these prescriptions.
In 1922, five years after passage of it’s resolution to denounce the use of alcoholic beverages as medicine, the AMA did a national survey – the Referendum on the Use of Alcohol in the Medical Profession. The results were interesting:
From alcohol not having any scientific value as a therapeutic agent just 5 years earlier, now doctors reported using alcohol to treat as many as 27 ailments including diabetes, cancer, asthma, dyspepsia, lactation problems, tuberculosis, pneumonia, high blood pressure and problems old age!
A group of doctors would even lobby Congress and eventually bring the case before the Supreme Court to be allowed to prescribe as much alcohol as they wanted and not the measly 10 pints every 10 days. Even though the group claimed that their motivation was not money bu the issue of independent practice and non-interference by the federal government, one could not help but think of the AMA survey.
Eventually, Prohibition would be repealed through the 21st Amendment in 1933 and a decade later, the practice of prescribing whiskey and brandy for ailments would slowly die out.
As doctors, we are asked to help or do no harm. Yet when money is in play, I wonder how many of us succumb and do things that may harm patients. Like the patients of yesteryear, yearning for their pint of whiskey, I wonder how many of us take a swig out of that exhilarating bottle of power, fame and glory and forget what we are supposed to stand for. I hope we of today are doing much better than those back then.

To undergo a surgical procedure, most people need some form of anesthetic.
If the procedure is small and does not involve a very deep incision, the surgeon can numb the area locally with local anesthetic and proceed. This technique is called local anesthesia and can be used even in a doctor’s office without the presence of a trained anesthesia provider.
The next level would be regional anesthesia. Using a local anesthetic, the nerve supply to a particular region of the body is blocked. This is great because not only does it allow the anesthetic to be localized but it also can be tailored to give pain relief for hours.
In instances where a local or regional anesthetic is not feasible or contraindicated, the other option is general anesthesia. Here, using either an intravenous or inhaled agent, loss of consciousness is achieved. This allows the patient to undergo surgery.
In a paper published in 2003, Vesna Jevtovic-Todorovic, an anesthesiologist then practicing in Virginia, exposed 7-day-old infant rats to a combination of two of the following – midazolam, nitrous oxide and isoflurane – for 6 hours. The exposure led to the death of nerve tissue in the developing brains of the rodents. Even worse, the rodents suffered long-lasting cognitive impairment in learning and memory, which worsened as they aged.
A few years later, the same phenomenon was observed when the same study was done using young monkeys.
This of course raised concerns in the anesthetic community, as many wondered if this phenomenon was possible in human kids.
Studies to correlate this in humans were lacking and retrospective analyses of data have given mixed results. This led to the F.D.A. and the International Anesthesia Research Society to form a group in 2009 to promote further research into this called SmartTots – Strategies for Mitigating Anesthesia-Related Neurotoxicity in Tots.
Even though there is still no human data, in 2012, the group recommended that elective surgery under general anesthesia be avoided in children younger than 3.
Late in 2014, they also stated that if an operation requiring anesthesia and sedation can reasonably be delayed, it “should possibly be postponed because of the potential risk to the developing brain of infants, toddlers and preschool children”.
At the moment, there is an ongoing study which has enrolled 700 children to study this phenomenon – A Multi-site Randomized Controlled Trial Comparing Regional and General Anesthesia for Effects on Neurodevelopmental Outcome and Apnea in Infants (GAS).
It is however not only children who seem to suffer possible negatives effects from general anesthetics on the brain. The elderly population seem to suffer from negative cognitive effects as well. Patients older than 60 seem more prone to develop delirium and some memory loss after general anesthesia and it is irrespective of the drug used. Patients with a history of dementia also fare worse.
Anesthetics cause their effect by blocking receptors in several regions of the brain (GABA, NMDA, Dopamine etc). Older patients may just have a harder time recovering from this block. There is the thought that anesthetics may induce neuronal changes that are harder to reverse in the elderly.
The use of regional techniques, when possible, prevents this problem.
One thing patients receiving general anesthesia worry about a lot is awareness. The fear that one would wake up during surgery and feel every part of the procedure. Awareness is a really rare occurrence. As the data is showing, anesthesia providers may actually be giving too much anesthetic when we use the classic definition of minimum alveolar concentration (MAC) to dose inhaled agents. This means patients are really “knocked out” and have a very slim chance of waking up. Even though explicit memory (conscious) is totally blocked, there is a chance that implicit memory (unconscious) may still be active and could lead to patients thinking they woke up. Also, chances are that as a patient emerges form anesthesia, he or she may erroneously think that they are still having surgery. Awareness is however possible during surgery of the very sick since those patients can hardly tolerate a deep general anesthetic.
So what does the future hold? The use of functional MRI during anesthetics may be a possibility in the future. We use the BIS monitor to gauge awareness but that might not be enough. Maybe the use of the EEG should be introduced. The introduction of newer drugs also hold some promise. It seems the best care in some case may be not to put patients to sleep.

The times leading to and after the passage of the Affordable Care Act aka Obamacare were tumultuous times in the US. There was the talk of death panels all the way to the fear of having a single payer system overnight.
Sure the law has had benefits in increasing the number of insured Americans but it is also dogged by financial problems. Just last year, several healthcare cooperatives, including one here in Kentucky, closed down. Several insurers, like United Health, have stopped offering plans on the exchanges and just this week, there are reports that premiums for maybe a million or more Americans might go up about 22%.
Probably the paramount reason is that most insurers underestimated how sick the uninsured population was. Also, the number of young and healthy persons who were forecasted to buy insurance and thus finance the program has been much lower. Most tend to pay the penalty and take their chances. Then is also the small issue of some state governors refusing to expand Medicaid to include more of the indigent population for political as well as fiscal reasons.
Beyond the financial issues, which have the ability to totally cripple the law, there are other unintended consequences. One of them results from the push by the law to consolidate medical providers into large groups.
In a piece published in the Annals of Internal Medicine in 2010, three of the leading healthcare advisors to the president then, and big proponents of the ACA – Ezekiel Emanuel, Nancy-Ann DeParle and Robert Kocher – wrote:
To realize the full benefits of the Affordable Care Act, physicians will need to embrace rather than resist change. The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups. The most successful physicians will be those who most effectively collaborate with other providers to improve outcomes, care productivity, and patient experience.
And thus began the move to consolidate all health groups.
In 2015, there were 112 mergers, up 18% from 2014. Even the insurers are merging. The belief was that large groups are more efficient in sharing information, managing costs and reducing risks for the patient.
As I always say, the experts who tend to write healthcare policy are often those who hardly do any patient care and this push to consolidate groups is another prime example.
Anyone who does any direct patient care will tell you that bigger is not necessarily better!
The push to consolidate is creating behemoths that are inflexible and take eons to react to change. It takes these larger groups longer to implement new policy or even effect cost savings.
These larger groups that were being encouraged were named Accountable Care Organizations or ACOs.
McAllen, a small town in Texas, was one of the most expensive places for healthcare in 2009. All that changed when the physicians there formed an ACO to provide value-based (preventative) and not activity-based (tests and specialist referrals) care. That little ACO outperformed the John Hopkins system interns of cost savings and outcomes in 2014 according to data from the Centers for Medicaid and Medicare Services. Several papers published recently show that physician-led ACOs outperform the much larger hospital-organization based behemoths.
The reasons for that are not difficult to find.
A lot of these hospital-organization based systems are often healthcare businesses that have bought groups at myriad places. The hospitals and groups are often scattered over counties and even states. They tend to be run from a central office, often far-removed from the individual centers of care. Hence, decisions are made that do not reflect the conditions that may favor any particular hospital or group. This then has an adverse effect on care at the affected hospital or group, negating any cost savings or improvement in outcomes.
Further, small groups offer more personalized care, which is a priceless commodity in medicine. It facilitates follow-ups and the tailoring of care to patients needs.
Also, the ability to use data is faster in smaller groups and technology can be implemented quicker.
Lastly, the patient experience in small community hospitals are also more pleasant. They do not feel like they are lost in a sea of faces and are just another medical record number.
It is really a pity that the ACA has pushed a lot of small and wonderful physician groups into these large inefficient behemoths. As the unintended consequences of this law gradually unfolds and we learn to make the necessary changes, I hope a push to smaller healthcare organizations will be paramount.

In 2014, a group from the San Diego Medical Centre led by Eric Macy MD, published an interesting retrospective study. They looked at healthcare use and prevalence of serious infections among 51,582 hospitalized patients with penicillin allergy. They found that these patients with penicillin allergy had an increased exposure to more broad-spectrum antibiotic, suffered more infections and were re-admitted more.
Coincidence? Not at all.
For years, it has been known that even though about 10% of the US population reports an allergy to penicillin, only about 1% of these cases are true immune-mediated allergies. Also, in cases of true immune-mediated reactions, 80% lose their sensitivity after 10 years. This matters because when a patient reports a penicillin allergy, most hospitals do not test for the patient to prove the veracity of that claim. Instead, patients are placed on broad-spectrum antibiotics like vancomycin and the fluoroquinolones. The use of these more powerful antibiotics leads to higher healthcare costs, increased risk for antibiotic resistance, and suboptimal antibiotic therapy. As we all are realizing, the issue of antibiotic resistance is no joke. Heard of Colistin-resistant E. coli?
Overall in the US, the incidence of such false drug allergies is on the increase and the consequences can be dire, as exemplified in the case of penicillin.
Now an adverse reaction to a drug is seen as any unwanted and untoward effect of said drug. These reactions include allergic reactions as well intolerance to it. Even the inability of the drug to work falls under adverse drug reactions.
Now a true drug allergy is mediated by the body’s immune system through antibodies – IgE as well as the T-cells. Since these are immune reactions, a true allergic reaction is not seen the first time one takes the drug. The body must be sensitized first. Where IgE mediates the really fast reactions like hives and angioedema, the T-cell mediated reactions takes days and weeks to become evident.
Data shows that less than 5% of adverse drug reactions are due to true immune reactions – so true allergies.
Yet, we are seeing patients with the most interesting allergies everyday. We’ve all heard them:
“Epinephrine (adrenaline) makes my heart race!”
“Beta-Blockers make my heart beat really slow!’
“Bernadryl made me sleepy!”
“Predinisone made me jumpy!”
“Aspirin tore up my intestines!”
These pseudo-allergies hinder optimal patient care in a lot of ways. They prevent the use of the the best drugs for the patient.
Several factors are contributing to this situation. A common factor buttressing all of this, is that more Americans are taking more drugs daily. One is going to see more adverse drug reactions.
The causes then split into patient and provider-related factors. Let’s do some scenarios (based on true events);
A patient notices a “bad” event while taking a drug A. He/She makes the erroneous connection that she has an allergy to drug A. Next time she is at her doctor’s or the hospital, she is asked by the triaging or admitting nurse about her allergies. She states she is allergic to drug A. The nurse just records it without further questioning and it is part of her history.
The patient call her doctor to tell him/her that she had a reaction to drug A. The doctor unwilling to bore and really find out the cause of said reaction goes, “You might be allergic to it. Let’s try drug B.”
A patient in the hospital is in pain after surgery. She is also having nausea. The physician orders a dose of narcotics to be given with an anti-emetic. The nurse does that. Fifteen minutes later, the patient is found apneic but successfully resuscitated. A day later, the patient is told she had an allergic reaction to the anti-emetic.
Years ago, a patient received novocaine at his/her dentist reaction office. There was an adverse reaction. According to the patient, she lost consciousness. She was later told she was allergic to all local anesthetics. It doesn’t matter that it might not have been the drug but where it might have been injected. Or that novocaine is an ester-based local anesthetic that is allergenic but quite different from the amide-based ones like lidocaine that are not.
A patient receives a peripheral nerve block for shoulder surgery. She emerges from general anesthesia in pain and nauseous. Well, the block didn’t work so the patient had to be given narcotics intraoperatively. In recovery, she is given more narcotics to treat her pain and ondansetron to treat the nausea. She erroneously concludes afterwards that the combination of local anesthetic, narcotics and ondanstron made her postoperative course so uncomfortable. She must be allergic to all those drugs. They appeared as allergies on her next visit!
Allergies have become a screen that practitioners can hide behind. They use it to get out of figuring out what is really going on or protecting themselves from a possible lawsuit. Patients on the other hand are quick to jump to erroneous conclusion. Conclusions that affect their care negatively.
Maybe it is time for most hospitals to employ an Allergy Czar. maybe institute an Allergy Tribunal. Then frankly, I’m developing an allergy to all these allergies.