Swallowed magnets: An attraction that can be fatal
By Christin Melton
Magnetic building sets are popular among gradeschool
children, but parents may want to refrain from
buying them for their youngsters. Between 2006 and
2008, the US Consumer Product Safety Commission
(CPSC) recalled more than 4 million toys that contained
magnets small enough for a child to aspirate or
ingest. Although most magnetic building sets with
small parts are recommended only for children 6 years
and older, the pieces frequently find their way into the
hands—and mouths—of much younger children. Also,
many parents assume incorrectly that children have
outgrown the temptation to put small toys in their
mouths by age 6. The CPSC reports that 10 out of 33
known cases of magnet ingestion involved children
older than 6 years. In 2004, Dr. Alan E. Oestreich
wrote to
Radiology about a 12-year-old autistic patient
at Cincinnati Children's Hospital Medical Center who
swallowed several magnets and suffered small bowel
necrosis and perforation. In the March 2006 issue of
Surgical Rounds, Dr. Scott Reed reported the case of an
11-year-old boy who had similar injuries after swallowing
several nuts and bolts along with a 1-cm magnet
(full text at
www.surgicalroundsonline.com).
While surgeons have long been aware of the risks
posed to children who consume magnets, the subject
attracted renewed media attention following a
February 2008 article in the Archives of Pediatric and
Adolescent Medicine. Four-year-old Braden Eberle
underwent laparoscopic surgery last spring to remove
two magnets, each barely larger than a pea, lodged in
his intestine. Eberle's surgeon, Dr. Sanjeev Dutta,
reported that the boy's intestine showed areas of necrosis
and perforation.
Today's toy magnets, made of inexpensive rare-earth
elements, are far more powerful than the ones most
adults remember playing with as kids. When a child
swallows multiple magnets or ingests a magnet in conjunction
with other metal bits (such as nuts and bolts),
the pieces attract one another through the thin lining of
the bowel wall. The body lacks sufficient strength to
separate and expel the objects. As in Eberle's case, the
magnets can pinch tissues together so tightly that the
blood supply is restricted, resulting in tissue death and
erosion. Magnet ingestion has been known to cause
perforation, volvulus, bowel obstruction, ulceration,
peritonitis, embedded magnets in the stomach lining,
and, in the case of one toddler, death.
Parents often attribute complaints of abdominal
pain to gastroenteritis or other mild stomach ailments,
which can delay diagnosis and treatment. Dr. Reed
warns physicians to be alert for "nonspecific symptoms,
such as excessive salivation, nausea, vomiting, or
respiratory difficulty." Dr. Julie Gilchrist of the Centers
for Disease Control and Prevention's Division of Unintentional
Injury Prevention advises physicians to consider
any foreign object observed on a child's radiograph
as a possible magnet and act accordingly. Note
that when magnetic materials adhere to one another,
they can appear as a singular object on radiographs. If
a child is suspected of having swallowed or inhaled a
magnet, magnetic resonance imaging should never be
used, for obvious reasons, Dr. Oestreich warns.
Parents need to be made aware of the dangers of tiny
magnets, and physicians need to keep magnet ingestion
in mind when evaluating children for abdominal pain.
Flat colorectal lesions are harder to spot than polyps
By Christin Melton
Just when new guidelines suggest that doctors consider
using virtual colonoscopy to screen patients for
colorectal cancer, a recent study in the Journal of the
American Medical Association (JAMA) calls this
method's efficacy into question. While virtual colonoscopy
readily detects the mushroom-shaped colon
polyps that can be found in up to 30% of adults, it cannot
detect nonpolypoid colorectal neoplasms (NP-CRNs). NP-CRNs are flat, depressed, or slightly raised
with a depressed center. They may exhibit discoloration
or redness but are often indistinguishable from
healthy mucosa. Roy M. Soetikno of the Veterans
Affairs Palo Alto Health Care System, the study's lead
author, describes them as looking like "a pancake at
the bottom of a pan." NP-CRNs are difficult to visualize
even when using traditional colonoscopy, especially
if patients fail to follow prescribed bowel preparation
protocols before undergoing the procedure.
The JAMA study examined 1,819 military veterans
who underwent elective colonoscopy. Patients were
mostly men, with an average age of 64 years. The study
population was divided equally into three groups:
screening, surveillance (those with a personal or family
history of colorectal adenomas or carcinoma), and
symptomatic. Before the procedure, each patient's
colon was sprayed with indigo carmine dye, an effective
way to highlight any NP-CRNs.
NP-CRNs were identified in 9.35% of all patients (n = 170), with a higher rate of occurrence (15.44%) in the
surveillance group. NP-CRNs were 10 times more likely
than polypoid lesions to contain cancerous cells "irrespective
of tumor size," and depressed lesions presented the
greatest cancer risk. American doctors have never been
very concerned with NP-CRNs, believing them to be
uncommon in the United States, but Soetikno emphasizes
that "[NP-CRNs] are important, because they are
much more likely [than polyps] to be cancerous."
Doctors who perform colonoscopies may need additional
training in identifying NP-CRNs. A 2006 study
in the New England Journal of Medicine concluded
that some physicians were 10 times more successful
than their colleagues at locating precancerous polyps
with colonoscopy. Accuracy correlated to time spent
conducting the procedure, and doctors may need to
take longer than the recommended 6-minute minimum
to ensure a thorough examination.
In addition to being hard to see, NP-CRNs are often
hard to excise. Dr. David Lieberman, a gastroenterologist
from the Oregon Health & Science University in
Portland, Oregon, and author of an editorial accompanying
the JAMA study, writes that "Complete removal of
the lesions may be particularly difficult since they have
indistinct borders that are hard to identify. Remaining tissue
can later turn into cancer, often between screening
tests." Further studies are needed to determine the longterm
prognosis for patients found to have NP-CRNs.
According to the American Cancer Society, nearly
50,000 Americans die from colorectal cancer each year,
making it the second leading cause of cancer death in the
United States. Approximately 108,000 new cases are diagnosed
annually, with the highest incidence in African
American men. Early diagnosis and treatment of colorectal
cancer offers a 5-year survivability rate of 90%. Yet despite
recommendations that all adults get screened at age 50,
almost half fail to do so, possibly because colonoscopy is
invasive or embarrassing and requires unpleasant preparation
and sedation. For reluctant individuals, virtual colorectal
screening is a better alternative than none at all, but
Medicare and most private insurance companies do not
cover the procedure. That, combined with the results from
the JAMA study, may mean patients will just have to take
their colonoscopy the old-fashioned way.
Keep it to yourself, doctor!
By Susan Haigney
Time is money, especially the time patients spend
with their physicians, and that limited time should
not be spent discussing what you did on your summer
vacation. In a study published in the
Archives
of Internal Medicine, researchers sent actors posing
as new patients to 100 experienced, primary care
physicians in the Rochester, New York, area who
had agreed previously to take part in the study.
Results showed that in 34% of these unannounced
fake-patient visits, doctors wasted time talking
about themselves instead of what ailed the patient.
Talk ranged from discussion about the doctor's
own health problems to his or her personal political
beliefs. Researchers concluded that 85% of these
discussions were useless to the patient, and 79% of
these conversations never returned to the reason for
the patient's visit. Eleven percent of doctors who
engaged in these off-topic discussions became disruptive
and argumentative with the patient during
the appointment.
Conquering the communication gap: Understanding your patient
By Janine Anthes
The quality of health care balances on the edge of
a growing rift in communication. Effective communication
is the foundation of successful diagnosis and treatment
and essential for ensuring superior patient care.
Health care organizations are responsible for communicating
complex medical information to a wide
range of people, yet the idea that communication has
been successful is often an illusion. Sometimes a physician
mistakenly assumes there is mutual understanding,
and other times a patient is too embarrassed to admit
feeling confusion and pretends to understand. "Effective
communication is at the heart of every health care interaction.
Ineffective communication—for whatever reason—can lead to ineffective health care and bad outcomes,
which means it's always an issue," suggests
Matthew Wynia, MD, MPH, director of the Institute of
Ethics at the American Medical Association (AMA).
Low health literacy
In an attempt to bridge the communication gap, the
medical community has turned its focus on addressing
the low health literacy level that plagues the United
States. According to the AMA, nearly 90 million people
in this country cannot read or comprehend the type of
information physicians commonly provide, such as instructions
printed on a pill bottle or patient education
materials for postoperative care at home. There is no
relationship between a low level of health literacy and
intelligence. Often, the confusion results from language
barriers, cultural differences, advanced age, or
the patient's inattentiveness due to pain or discomfort.
When you consider the vast and ever-increasing diversity
among our country's population, the possibility of
having patients whose health literacy is not up to par
may be greater than most physicians imagine.
"We've just gone through another national survey,
and somewhere between 16% and 20% of the population
has a really serious reading problem. They're
saying below basic," says Joanne Schwartzberg, MD,
Director of Aging and Community Health at the AMA.
"So we know where we need to go, but we don't know
how to get there," Schwartzberg adds. US Census
Bureau statistics show that 1 in 5 Americans speaks a
language other than English at home, and 8.1% of the
population has limited English proficiency, which the
Census Bureau defines as the ability to speak, read, understand,
or write English "less than very well." This is
projected to increase to 10% of the population by 2010.
It is becoming more important than ever to find ways of
breaking down language and cultural barriers to ensure
that patient care is not compromised.
Wynia cites informed consent as an area where cultural
misunderstandings can come into play. "People
who grew up in America know about the litigious climate
of American medicine," Wynia says. "So physicians
run this litany of 'well, you could have an infection,
you could bleed, you could even die if that's the extreme'—and sign here." Someone raised in another culture
may see the physician as being incompetent, while
others may consider it bad luck to discuss bad outcomes.
Where to start
Schwartzberg says to make sure the patient is clear
on what you are telling them. "Ensure the patient understands
you by speaking simply and directly and by
using what we are calling a ‘teach back.' Ask the patient
to summarize the key points that you've discussed.
Make sure the patient understood them," Schwartzberg
says. "The extent of the shame and embarrassment of
these patients is another thing you want physicians to
understand. These are very sensitive, very difficult issues,"
Schwartzberg adds. "Doctors are very skilled in
talking about difficult issues with patients. The same
kind of nonjudgmental ways they use to make people
feel comfortable and bring up subjects that are very
painful, they can use in terms of [fostering] patient understanding."
It is important that patients do not feel
disgraced when they do not understand, and they need
to feel comfortable asking questions.
Malpractice concerns
The risk of facing a malpractice lawsuit is a significant
enough reason on its own not to ignore this concern.
"The responsibility to communicate successfully
rests with the provider, not with the patient," says
Steven Levin, MD, who was named 2007 Family
Physician of the Year by the American Academy of
Family Physicians. "It's not a legal excuse that the patient
didn't understand." Schwartzberg cites the Joint
Commission as reporting that 65% to 80% of all medical
errors concern communication failures. Some cases
involve provider-to-provider communication and others
concern interaction between provider and patient.
"Malpractice lawyers have told us it's primarily communication
issues," Schwartzberg says.
Did you know...
79%—Percentage of
Americans who feel that
current American culture
makes it hard to exercise
regularly and maintain a
healthy lifestyle.
(International Health,
Racquet & Sportsclub
Association, 2007)
38%—Percentage of consumers
concerned about
not being able to pay medical
costs associated with a
serious illness. (Experian-Gallup Personal Credit Index
Survey, 2007)
28%—Percentage of consumers
concerned about
not being able to pay the
medical costs for normal
health care. (Experian-Gallup
Personal Credit Index Survey,
2007)
$68—Average monthly premium
for short-term health
coverage for an 18- to 24-
year-old. (Money Magazine,
2007)
$10,402—Average cost to
repair a broken leg. (Money
Magazine, 2007)
|
Another potential for error concerns medication.
"I think errors around prescriptions are the second
most common reason for malpractice suits, and
that's probably just the tip of the iceberg,"
Schwartzbeg says. She adds that close to 30% of hospitalizations
of elderly patients result from an adverse
event involving medication, either stemming
from noncompliance, doses that are too high or too
low, or drug interactions. Schwartzberg points out
that "Patients older than 65 have an average of 7 or
8 different physicians who prescribe for them, and if
you have 5 chronic illnesses and you're over 65, you
may have as many as 14 different doctors prescribing
during 1 year—and they don't know about each
other. So the potential for error is great."
In an attempt to minimize the potential for these types
of errors, an increasing number of physicians are adopting
the brown-bag
method. The physician
asks that the patient put
every medication taken
on a regular basis into a
brown bag and bring it
to the next appointment.
At the appointment,
the physician asks
the patient to describe
what each pill is for and
when it is taken. This
helps ensure that the
physician knows exactly
what medications the
patient is using and how
they are being used.
Wynia reminds physicians
that "If you fail
to provide effective
communication you're
going to end up having
mistakes and those mistakes
could be really
costly." While it is difficult
to determine
whether your efforts
have resulted in averting
any really bad outcomes,
it is worth remembering
that it only
takes one debilitating
malpractice suit to devastate
a physician's career.
The impact poor
communication has on
the medical community
may not always make headlines, but it is a looming giant
and has greater consequences than most people realize.
As the demographic of our population shifts upward in
age and as we continue to grow more diverse, physicians
need to remain vigilant on this issue, to protect not only
their patients but also themselves.
