Learn the Ups & Downs of Occupational Medicine Contracts

Katherine West, BSN, MSEd, CIC | From the January 2013 Issue | Thursday, January 24, 2013

Your agency may not be getting the most it can from its occupational medicine program.

Photo Capifrutta/istockphoto.com

Many departments across the country have been signing contacts with occupational medicine groups for a variety of services, including annual physicals, hepatitis B vaccine administration, tuberculosis (TB) testing and post-exposure medical follow-up and counseling. The question: Is this all these occupational medicine groups offer in the way of services? Are they actually offering the practice of occupational medicine, or are they functioning more like a “doc in the box?” In other words, is your department getting the full value of what an occupational medicine practice should or can offer?

The definition of the practice of occupational medicine is as follows: “Occupational medicine focuses on the health of workers, including the ability to perform work; the physical, chemical, biological and social environments of the workplace; and the health outcomes of environmental exposures. Practitioners in this field address the promotion of health in the workplace and the prevention and management of occupational and environmental injury, illness, and disability.”1 This definition suggests that occupational medicine services are actually broad.

Post-Exposure Issues
With regard to post-exposure medical treatment and counseling, the training for occupational medicine providers is generally not present. If the occupational medicine group your department is using offers this service, it would be important to interview and document their specific training in this area of care. This is important, because the Occupational Safety and Health Administration (OSHA) holds the employer responsible for the proper administration of post-exposure care and counseling—not the care provider. The occupational medicine practice is only acting as an agent on behalf of the contracting department and would not be cited by OSHA if proper care wasn’t in place. However, your agency or your government authority—would be.

Some occupational medicine groups sub-contract out post-exposure care and counseling to an infectious disease physician, who is best qualified for handling post-exposure events. Infectious disease practices deal with these issues on a day-to-day basis, so there would be quality of care and consistency of care.

This begs the question: Why use the middle man? If this is the case for your department, look at the cost you’re paying on the contract and determine if this is the best routine to follow.

Another factor is availability of the service. When assessing the use of an occupational medicine group for post-exposure issues, asking key questions before selection and signing on the dotted line is very important. Is the occupational medicine practice available for coverage for exposure events 24 hours a day, seven days a week? If constant coverage isn’t available and you’re required to use an emergency department (ED) during “off” hours, then the cost of care for your employees increases, and the proper care and counseling may not be delivered.

Agency Audit
If you’re currently using an occupational medicine practice, then you might consider conducting an audit. This will assist in protection for your department if an OSHA inspection was to occur, and will identify any areas in need of improvement. The goal is to protect care providers and ensure the department is meeting its needs for compliance.

Vaccines/Immunizations
On Nov. 25, 2011, the Centers for Disease Control & Prevention (CDC) published new guidelines for vaccination and immunization of healthcare personnel. In this document, the CDC states that these records are to be secure and computerized for easy access. This is to facilitate prompt/proper post-exposure medical treatment.

In today’s world, old diseases are back and many individuals are in need of re-vaccination or vaccination. For example, if you received measles, mumps, rubella vaccine (MMR) between the years of 1963 and 1967, you need to be re-vaccinated with the live measles vaccine.

Did your occupational medicine group notify you about this? Was your department notified in 2006 that all healthcare workers were to get boosters for protection from pertussis (whooping cough)? These types of alerts should be included in their role and service. All new hire personnel should be asked to bring copies of their vaccine/immunization records as part of the hiring process. This will assist in the identification of personnel who are in need of vaccines because they haven’t had the diseases or are in need of a booster.

In 2006, the CDC published that all healthcare personnel needed a booster for protection from pertussis. This was not well responded to and was published again in 2011. Occupational medicine groups should be tracking this type of information and sharing it with their clients. Previous vaccine/immunization records can be obtained by an individual from their high school, college or past employers. Each individual must request their records, and should be able to obtain them,
because those records legally belong to each individual.

Current members of your department also need to put forth their records for review of their protective status and childhood disease history. This is all part of health maintenance and prevention from exposure to these diseases. Some of these vaccinations don’t work if given post exposure. This would apply to MMR, for example. Obtaining this information is in your best interest for your protection and also works for the department’s benefit because prevention up front is far less costly than exposure follow-up.

Clearly, the need for expanding protection beyond hepatitis B vaccine and TB testing has long passed. Your occupational health practice should be tracking and maintaining records on all administered vaccine and immunizations.

The CDC stated in May 2008 that these records need to be “readily available at the work location.” If they aren’t available to the Designated Infection Control Officer (DICO), then treatment may be delayed or unnecessary treatment ordered. Your designated officer needs to be able to access these records at any time in an exposure situation.

Data Collection
The CDC and OSHA also have requirements for annual data collection as part of annual education and training and exposure control plan updates. Annual reporting of sharps-related injuries, TB risk assessment and airborne/droplet exposures should occur.

There’s also a need to support the TB risk assessment by conducting TB conversion rates. TB conversion rates are new positive TB tests in department personnel since the last testing period.

This information should be provided by the occupational medicine practice, especially if they are administering TB testing. Departments should also be provided with information regarding the percent of personnel that do not return in time to have their TB skin tests read at 72 hours and have to have them repeated.

This adds to department cost and may enter into a decision to switch over to one of the TB blood test that doesn’t require a return visit or a two-step testing process. A department’s need to perform annual TB testing depends on the number of active untreated TB patients that the department transported in the previous 12 months. Many occupational medicine groups aren’t aware of this and are still advising annual skin testing. Is it better to just do annual testing anyway? No. Continuing annual testing when not needed may lead to false positive test results. More is not always better.

The CDC is now asking that compliance rates with annual flu vaccine be reported annually and that this information be incorporated into annual training in an effort to boost participation. This information should also be tracked and provided by the occupational medicine group. Occupational medicine groups should be spearheading the effort to increase participation rates.

Exposure data should be reviewed on an annual basis and determination made regarding the number that may have been preventable, and recommendations for prevention and educational needs be offered. This may assist in the identification of purchasing needs and serves as a form of compliance monitoring. Compliance monitoring is a required component of OSHA’s exposure control plan.

Work Restriction Guidelines
When should you be at work and when should you stay home due to illness? Work restriction guidelines were originally published by the CDC in 1997 and were updated in November 2011, and should be part of each department’s exposure control plan used by the occupational medicine group. The guidelines offer clear information on when staff is fit for duty or when they should be off duty. Working when ill increases your risk because your immune response is lowered and poses a risk for transmission of your illness to co-workers.

Are these guidelines in place in your department? Vaccine declination forms are an OSHA requirement and are also addressed by the CDC and in NFPA 1581. Is your occupational medicine group collecting them? Your department should get a report on the percent of declination forms signed and an evaluation of the reasons for individuals declining.

Ensuring Compliance
The practice of occupational medicine is much more than simply the administration of hepatitis B vaccine, flu vaccine and TB testing. It also involves the collection of data important to maintaining health and safety of personnel in a department. Because the occupational medicine practice works for your department on a contract basis, conducting an audit for OSHA compliance and ensuring the CDC guidelines are being followed is important. OSHA is responsible for enforcing many of the CDC guidelines, and if they’re not followed, a citation is given to the department.

When contracting with an occupational medicine group, your department should present a list of identified needs, and ask if they can be delivered and at what cost. Using a letter of agreement is also a good idea. The letter should state that the practice will adhere to the CDC guidelines. This offers added legal protection for your department because the CDC guidelines are the medical standard of care.

Many departments put these responsibilities and compliance in the hands of the occupational medicine practice with no oversight to ensure compliance and no cost analysis. Is your department being told you need annual TB testing no matter what your risk assessment shows? Similarly, is your department being told that annual hepatitis B titers are needed annually or that hepatitis B titers are to be performed on all new hires?

If the answer to any of these questions is “yes,” then there’s a problem. None of these is recommended by the CDC, and an audit for OSHA and CDC compliance is in order. The department’s DICO officer can play an important role in performing this audit, and a relationship should be established between the DICO and occupational medicine service.

The DICO serves as a liaison between the department and the treating entity for compliance and quality monitoring. The DICO works to benefit department members, but they also work for administration to ensure compliance and quality of care. Remember, the CDC guidelines set the standard of care, and OSHA enforces most of them, but ultimately, the department is held responsible for compliance.

References
1. Occupational Health & Safety Administration. CPL 02.-02.069: Enforcement procedures for the occupational exposure to bloodborne pathogens, occupational health & safety administration, Nov. 27, 2001. In U.S. Department of Labor. Retrieved Nov. 1 2012, from www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=2570.
2. Advisory Committee on Immunization Practices: Centers for Disease Control and Prevention (CDC). Immunization of health-care personnel, recommendations of the advisory committee on immunization practices (ACIP).MMWR Recomm Rep.2011;11(60):1–3.
3. Jensen P, Lambert L, Iademarco M, et al. Guidelines for preventing the transmission of mycobacterium tuberculosis in health-care settings. Morb Mortal Wkly Re. 2005;12(54):1–141.
4. Center for Disease Control & Prevention. Evaluation of results from occupational tuberculin skin tests: Mississippi, 2006. Morb Mortal Wkly Re. 2007;56(50):1,316–1,318.

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COL Jamie Grimes on Traumatic Brain Injury in OIF/OEF

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Revolving Door of Multiple Tours Linked to PTSD

Contributor:  Sharon Cohen
Posted:  04/14/2010  12:00:00 AM EDT  |  1

It wasn't his first tour in Iraq, but his second and third when Joe Callan began wondering how long his luck would last — how many more months he could swerve around bombs buried in the dirt and duck mortars raining from the skies.

It was only natural, considering the horrors he'd seen: One buddy killed when a mortar engulfed his tent in flames. A fresh-faced Marine sniper dead (also a mortar) on his first day in Iraq. A 9-year-old Iraqi boy, blood trickling from his head, after he was mistakenly shot by U.S. troops. An Iraqi grandmother collapsing from a heart attack after her home was searched (she later died).

Three tours in four years and Callan wanted out. Out of Iraq, out of the Marines.

"I became numb," he says. "None of it mattered. I just wanted to be home. And that became more intense each time."

When Callan did return to New Mexico, he couldn't sleep. He drank heavily. He had a short fuse. "I knew," he now says, "I was different. But I didn't think it was going to be that bad."

Maj. Jeff Hall's world imploded after his second tour in Iraq.

Overwhelmed with guilt and rage, the 18-year Army veteran became so depressed that one day he lay on the ground and pointed a pistol at his head. The only reason he didn't kill himself, he says, is he didn't want his two daughters to discover him after school. "I couldn't do that to my kids," he says. "I had seen people with their heads blown off."

But the war had pushed Hall to the brink. "I wanted everything to stop," he says. "I had no peace at all."

No peace — on the battlefields of Iraq and Afghanistan, or in the minds of men and women who fought there. Callan and Hall are among hundreds of thousands of U.S. troops who've served multiple tours; they're also among the tens of thousands diagnosed with post-traumatic stress disorder.

That is not a coincidence.

With two long wars — Afghanistan is in its ninth year and Iraq just entered its eighth — the U.S. military finds itself straining to maintain a steady flow of troops. More than 2 million men and women have been deployed to serve in both conflicts, and more than 40 percent of them have served at least two tours, according to military records.

Nearly 300,000 troops have served three, four or more times. And, records show, more than half of those currently at war are at least on their second tour. (The vast majority of deployments last more than six months.)

For these men and women, life becomes a revolving door of war, home, then back to combat — sometimes within months — as they face the same dangers, the same stresses and the same agonizing separation from family. Some soldiers are gone so often, they're more comfortable being away.

"You feel as if Iraq is your home, you feel that's where you ought to be," says Justin Taylor, who says he suffered a mental collapse after his third deployment to Iraq.

Multiple tours, according to several studies, have been linked to stress, anxiety and PTSD, which is often marked by nightmares, flashbacks, angry outbursts, insomnia and social withdrawal.

"It's common sense," says Dr. Judith Broder, founder of The Soldiers Project, which provides free, confidential counseling to returning troops and their families. "The more deployments there are, the greater the danger not just of combat stress but depression. ... Virtually everyone comes back with some kind of sleep disorder. Many people also feel alienated and isolated from their family."

                                                            ———

After two Iraq stints 10 months apart, Maj. Jeff Hall wanted to be left alone.

He felt he'd been a failure; he believed he hadn't helped the Iraqis or really accomplished anything. He urged his wife, Sheri, to take their two daughters and leave. She refused.

So Hall would take off by himself some days, hopping on his Harley and driving 1,000 miles to west Texas, the Oklahoma Panhandle — any place, just to get away. Other days he couldn't bear to go to his job at Fort Polk, La.

Looking back, Hall can pinpoint the day he realized something was terribly wrong. It was after his first tour, when his family was having dinner at a restaurant and his daughter, Tami, then about 12, refused to touch her steak because sour cream had gotten on it.

Hall began crying.

His family was stunned. So was he.

"What's wrong with dad?" Tami asked.

What Hall didn't reveal was his daughter's fussiness had dredged up memories of a very poor family in Iraq that would regularly pick up gas for cooking at a propane station he had guarded. Their two girls — close to his daughters' ages — were so emaciated their skin hung like loose cloth.

"I could just see the faces of the little girls," Hall says. "It kept recurring to me. It triggered a feeling of sadness and anger and all kind of emotions."

But suicidal thoughts didn't surface until after Hall's second deployment, which was even bloodier and more aimless than the first. "It was like we were driving around until we got blown up," he says. Roadside bombs — called improvised explosive devices — had become so common that when Hall studied a map of where they'd been found in the last six months, it was one giant red blob, without a hint of road.

In the first few months, Hall's brigade lost more guys than the entire year in his first tour. One day a Humvee under his command ran over a massive IED, blasting a huge crater in the soil, killing two soldiers, seriously wounding another.

"I felt shame, absolute shame," Hall says, recalling how he smoked a pack of cigarettes in 20 minutes and couldn't sleep for days. "I was suffering from guilt, from the loss. We were having no results. I described it to the psychologist two years later ... It was like a complete loss of identity, a loss of ideals and how you think life is or should be."

Sheri, who had been encouraging her husband to get help, finally called his commander. That led to a civilian psychologist and a diagnosis of PTSD.

"I thought my career was over," Hall says. "I thought, 'What am I going to do?' At the same time, I had this feeling of 'Aha, there IS something wrong. I'm not making this up.'"

                                                             ———

There's no way to know for sure how a soldier will react to multiple tours.

Some go to war four times and never have a problem. Some deploy once and are forever changed. Others never leave the United States and develop PTSD.

Justin Taylor's breaking point came on his third stint in Iraq. The former Army sergeant started having anxiety attacks. He vividly remembers the first one.

"I couldn't breathe," he says. "We had mortars coming in. I was shaking and (a friend) said, 'Dude, are you OK?' When I had to go on patrol, I started feeling it. I had to suppress it. I couldn't tell my boss I couldn't go."

Back home, he began drinking so heavily, he'd black out. Within months in early 2007, he got his marching orders for a fourth tour and told his (then-estranged) wife: "If I go back, I'm not coming home.'"

He knew that was a dangerous feeling.

"If you've got a death wish or think you're going to be die," he says, "you're not going to be able to lead your soldiers or perform your duties."

Taylor says when he told a captain in his company, the officer chastised him, saying: "'You're an alcoholic. We're going to cure you by sending you back to Iraq.'"

A civilian psychologist at Fort Carson, Colo., he adds, told him he was faking PTSD to get out of going back. He admitted himself twice to a mental hospital and received an honorable discharge.

Soldiers face the kind of repeated stress — much like police and firefighters — that piles up, says Dr. Paul Ragan, an associate professor of psychiatry at Vanderbilt University and a Navy psychiatrist for the Marines during Desert Storm.

"The bottom line is trauma is cumulative," he says. "It embeds itself in your brain and you can't shake it loose."

Military in-field surveys support the notion.

A 2009 report of Army troops in Afghanistan found the rate of psychological problems rose significantly with the number of deployments: 31 percent for three tours, more than double the rate of those with just one.

In Iraq, the survey found nearly 15 percent of Army troops who served two tours suffered from depression, anxiety or traumatic stress, more than double that of single tour. When it came to PTSD alone, the rate was 2.5 times higher for two deployments compared to one.

"We just don't know whether it's combat exposure, repeated separation from the family or (not enough) time off," says Lt. Col. Paul Bliese, director of the division of psychiatry and neuroscience at the Walter Reed Army Institute of Research. "All of those are reasonable explanations."

Other research supports these findings. A Stanford University study — based on a mathematical model — estimates the risk of PTSD for those serving one tour will be 24 percent five years after returning home. It jumps to 39 percent for a second tour, and a staggering 64 percent for a fourth.

And a recent study of New Jersey National Guard members who had served in Iraq or Afghanistan found nearly one in five of those redeploying to Iraq screened positive for PTSD. The study also found "surprisingly high" rates of PTSD and alcohol abuse just days before these soldiers were returning to combat.

The findings raise serious questions about the military's ability to screen soldiers for psychological problems before sending them back to war, says Dr. Donald Ciccone, a study author and associate professor of psychiatry at the New Jersey Medical School.

It's not just combat that's emotionally draining. It's also the separation from families.

"When you come home, it's not like everything is peachy keen," Ragan says. "You're trying to re-establish yourself with your family, then you're gone again. How many times can you do that?"

And yet, some troops do want to return, says Broder, of The Soldiers Project. "The big motivation is to be with their band of brothers," she says. "These are their tightest bonds."

Sam Rhodes, now a retired command sergeant major, was home about 40 days when he eagerly returned to Iraq a second time. "I just supported the war. I felt comfortable there and I felt that's where I needed to be," he says.

It was on his third tour when he collapsed — both physically and mentally. He was diagnosed with PTSD.

The loss of seven soldiers in his brigade in a single month proved especially traumatic. "You've got high expectations," he says. "You think you've learned a lot in the previous deployments and you think 'I'm going to do a better job of getting my guys home.'"

When Rhodes came home to Fort Benning, Ga., in 2005, he and his wife of 26 years divorced.

"She says the war took the man she married away from her, that I would never be the same ... (But) the war didn't change me," he says. "It gave me a better perspective of what's important in life."

And yet, Rhodes, who has since remarried, now believes he should have taken a break of a year or more between tours.

Many experts believe soldiers aren't home long enough — the military phrase is called dwell time — between tours. The Army study found it averaged 17 months, short of the two to three years considered optimal.

Ryan McNabb, a former Navy corpsman attached to the Marines, had four months between his two stints in Iraq — by choice. He volunteered for a regiment he felt would face less enemy fire than he saw on his first deployment.

At Al Asad Air Base on his second tour, McNabb had time to think. Maybe too much. He worried. About his mother and father. About his brother and sister. Even about his aunts and uncles. He'd try calling them. If there was no answer, he'd worry they'd been in a car accident.

"Your mind is like, 'Hey, things are fine.' But no, they can't be fine," McNabb says. "You're thinking, 'I'm in Iraq, people are dying right and left. Or there's a sandstorm coming. I have to worry about something, I have to keep my mind going.' The more I'd sit and think, the more I'd get depressed."

And it wasn't always about combat.

One day Marines found two little physically disabled Iraqi brothers, maybe 2 and 3, chained to a brick by their father. McNabb cleaned, diapered and fed them — but was pained when they had to be returned to their father.

Returning to North Carolina in 2006, he found comfort in booze: a pitcher of beer at lunch, a 12-pack at night. "I was a high-functioning drunk," he says. "I could drink and drink and drink and never go to sleep. It made me feel good."

It also led to a night in jail after an intoxicated McNabb punched a police officer.

McNabb transferred to Italy, where he met his wife, Mandy. For a time they moved to California, where he stopped drinking. But he couldn't control his anger.

Once when his wife couldn't quiet their crying 8-month old son as they headed to see Santa Claus, McNabb pulled the rearview mirror off their speeding car and smashed the global positioning system, shattering the windshield.

Others noticed McNabb's troubles, but he was slow to acknowledge them.

"When you're talking about PTSD, you don't want to admit it to anyone or it's, 'Oh, yeah, I got a little. I've got 1 percent' .... In every good Mel Gibson movie, he has a blackout, he has cold sweats," McNabb says. "I didn't have that."

Finally, his brother, Brock, an Army veteran of two Iraq tours, referred him to a center run by the Department of Veterans Affairs, where a counselor, a former Marine who'd served in Vietnam, proved an enormous help.

McNabb, now 29, works as an outreach coordinator for a Vet Center in suburban Chicago. He still is being treated for PTSD, and while Iraq is fresh in his memory, he's not eager to share war stories.

"It's like a drink. It makes you feel good right now," he says, "but in the long run, what's it going to do?"

                                                             ———

The much-publicized suicides linked to PTSD are very real. But so are the stories of those who find ways to survive.

Jeff Hall took the pistol from his head and put it down. He eventually found help in an intensive three-week treatment program at Walter Reed he attended with his wife.

"It gave me hope that there was a chance I could heal," he says. "It didn't make me feel so damned crazy."

Hall is now creating the resilience campus at Fort Riley, Kan. The program will help soldiers and their families rebound from multiple tours and deal with the stresses of war and everyday life.

Still, he does not consider himself cured of PTSD.

"I don't believe that you get over it," he says. "I think you learn to live it with it. I think you learn not to let it control you. You learn to control it. That's where I am. It took a long time to get there."

Sam Rhodes, the retired command sergeant major, has written a book about his own experiences, "Changing the Military Culture of Silence." He travels the country, talking to military and civilian audiences to demystify PTSD.

He carries in his pockets photos of soldiers who killed themselves when they were consumed by depression — and occasionally displays them to remind people of what can happen.

Rhodes still struggles with his own anxieties: A war movie, patriotic music or the crackle of a gunshot can stop him in his tracks or bring tears to his eyes.

"I tell people, 'Look, I'm going to have PTSD the rest of my life,'" he says. "Only a normal person can go to war and see the things we have and feel what we have when we come back. If you're rock hard and have no feeling of loss or anything, that's what's abnormal."

Joe Callan, now 31, has always been rock hard. Growing up in rough neighborhoods and on a Navajo reservation exposed him to some harsh realities of life that were magnified thousands of times over in Iraq. He saw friends die, endured IED blasts and in one three-month period, faced almost daily mortar attacks.

His survival strategy was hang tough, be tough.

"I always ran at the problem. If we were getting shot at, I'd run at the bullets. If you shoot back more than they're shooting at you, you'll win," he says.

Callan says he was told after his second tour that he probably had a stress disorder. He shrugged it off.

He ended his 11-year stint in the Marines two years ago, and it was then that his life unraveled in a familiar pattern: Depression. Insomnia. Anger.

These days, Callan's not especially worried about having PTSD. He figures many of his Marine buddies are in the same boat, with worse symptoms.

He has rebounded, though he's still adjusting to a life where he doesn't have to worry about ambushes, bombs, crowds — or what's behind him. He can now sit in restaurants without watching the entrance. "It makes me tense in my shoulders and my back," he says, "but I can do it. A while back, I wouldn't have had my back to the door."

Callan credits his wife, Katy, their three kids and other family with helping him recover. Callan has been in and out of VA counseling; he has little time for that kind of stuff.

"I have to suck it up," he says, "because people are depending on me."

He has found renewed purpose in a job: He's now an organizer for Iraq Veterans Against the War. Soon, he hopes, this war will be over.

"I just want to have a small farm," he says, "hang out with my family, grow evgetables and be left alone.  I just don't want to be a part of it anymore."

Sharon Cohen is a national writer for The Associated Press, based in Chicago.

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Military Chaplains on Psychological Well-being and the Importance of Warfighters Mental Health.

Posted: 05/11/2010

A panel of two senior military chaplains (CAPT Shelia Robertson and CAPT Jessie Tate) and a clinical psychologist (Dr. Elmer Maggard) discuss how psychological, mental, and spiritual well-being are critical components to keeping our warfighters healthy and fit for duty.  With a rise in the reported PTSD cases coming out of OEF/OIF and with many service members returning home from combat with physical disabilities, the role chaplians play in military medicine is as important as ever.

Tags:   Military Chaplains | Mental Health | Military Medicine

Military Chaplains provide counseling both at home and overseas to servicemembers and their families and play a vital yet often unseen role in providing guidance and support that helps our men and women in uniform recover from physical and emotional wounds.

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Saving Lives and Limbs

Contributor:  CAPT Michael Vengrow, MC, USNR
Posted:  04/15/2010  12:00:00 AM EDT  |  4

It's Time to Give the Marines a Dedicated Medivac Helicopter

Are Army infantry soldiers more important than Marines as human beings or as components of U.S. defense strategy? If this strikes you as a preposterous and insulting notion in 2006, more than six decades after Iwo Jima, consider the fact that Marines still do not have a dedicated medevac helicopter—a nicety of war that is all about saving limbs and lives and that Soldiers have had for many years.

It is time to change medevac doctrine for the U.S. Marine Corps-Navy team. The doctrine is an anachronism that serves no one very well, least of all the Marines who fight on the front lines and display such incredible valor.

An Expeditionary Requirement

The mission of the Marine Corps is expeditionary by its very nature.  A helicopter dedicated to the men and women of the Marines would directly support that branch’s mission.  Currently, on the way back from a mission, Marine helicopters transport casualties as a lift of opportunity.

But no Marine or Navy dedicated medevac helicopters are in the U.S. inventory. In Operation Iraqi Freedom, the  1st Marine Division had one designated CH-47 helicopter  for medevac. It was an embarrassment—a stripped down CH-47 with no medical equipment, no ventilator, no true stretcher capability, and in short, nothing that would even look like the kind of civilian helicopter ambulance that we are accustomed to seeing on television.  

The Army’s Blackhawks have stretchers for up to six patients on a carousel with ventilator capability just like a civilian helicopter. It should be noted that the definition of a “dedicated” medevac helicopter is one that is outfitted as a true air ambulance, has a red cross on it, and seen as part of the Geneva Conventions. A “designated” medevac helicopter, on the other hand, may or may not always be used to take out casualties and it has no medical infrastructure or red cross; therefore it is not part of the Geneva Conventions.

In the future, joint operations will continue to share assets, but the Marine Corps is operationally an expeditionary/amphibious force, and as such, in conjunction with the Navy will be involved in operations that are more unilateral than in the past. The Marine Corps-Navy team has a single battle strike capability. Today, the United States is fighting a global war on terrorism and casualties are different from other wars.  

USA Today reported in September 2006 that more than 1,000 American military have been killed by improvised explosive devices (IEDs) and more than half of the 20,000 wounded were the result of IEDs.  These devices cause primarily loss of limb or traumatic brain injury. The majority of wounds therefore were from blast injury and not gunshot injury.

We are and have always been good at preventing mortality (loss of life), but we can do much better to prevent morbidity (everything short of loss of life, such as loss of limb or limbs, brain injury, or eye injury). The Navy has developed the Forward Resuscitative Surgical System (FRSS), but it has limited capability and falls considerably short of what is needed (it has room for one general/trauma surgeon, one anesthesiologist, and maybe an orthopedist).

The “Golden Hour”

It is said that rescuers have a “golden hour” to prevent the death of a wounded combatant. To save limb and brain function should be the first choice of a medevac mission in a war on insurgency, when the injured numbers of Marines are variable at a time.  If unavailable, then the FRSS or other venue should be used. And that other venue may be another service or country of opportunity. 

But if the Marine Corps-Navy team stands alone in an amphibious operation, then medevac capability has to go to the primary casualty receiving treatment ship (generally a large-deck helicopter carrier).  This should be the first choice, and this department on the ship should be more robust than it is now. The FRSS has great value but does not replace the level III facility or its smaller components on land that also must be restructured.

But, remember, surgeons need to operate to keep their skills up, and deploying them for a year may not be in their and the Navy’s best interest.  Add to this the reserve doctors who are generally older, more experienced, and usually subspecialists.  They are routinely echelon I (first level of stabilization/care) doctors for Marine battalions—the lowest level of care. General officers in the Marine Corps will tell you that all an echelon I doctor has to do is scoop up the wounded and get them out of the area to a hospital of some kind. They don’t need any telecommunications. 

This may be true in a conventional war where the casualties are in the hundreds. But in an insurgency war the injured may number as few as one to several, and because of the different type of weapon exposure, the wounded may require immediate specialized care.  It would be prudent for the echelon I doctor to have satellite phone capability to communicate to appropriate specialists for movement.  Why? Because the specialists are fewer in number in the battlefield environment and this works in the civilian world.

Applying what we know from the civilian world of emergency care and movement is not problematic. It just takes an adjustment in thinking. Last, using the same argument about degradation of skills, and in particular that the reserve doctor is a citizen military doctor, he or she needs the same foresight in deployment length.  They, too, need the benefit of shorter rotations to 30-90 days so that they can preserve their private practices. The global war on terrorism is going to be a long war. We need all the skills that we can get. 

Otherwise, the Navy will be selecting for VA or university doctors only, and in time of war that degrades the pool number and selection of skill sets. But, there is always room for improvement, and we should settle right now for the dedicated Navy helicopters that the Marines so richly deserve.  If that happens, we then can move on to other challenges with the potential to save even more limbs and lives.

* Reprinted from Proceedings with permission; Copyright © 2007 U.S. Naval Institute/www.usni.org.

Captain Vengrow is a Dallas-based neurologist who served as an echelon I
doctor and later as a Task Force Surgeon Scorpion (Marine), staff CJTF 7
medical cell officer in Operation Iraqi Freedom in 2003. He has extensive
training and certification as a Surface Warfare Medical Department Officer,
Seabee Combat Warfare Specialist, and as a Marine Corps physician.

function submitCommentsOrder() {var commentsOrder = $('#commentsOrder').val();$('#setCommentsOrder').attr('action','/article.cfm?externalID=2254&commentsOrder=' + commentsOrder);$('#setCommentsOrder').submit();}  Comments Sign in or Sign up to post a comment andrea58 07/21/2010 6:25:27 AM EDT

I fully agree with the article point of view about the necessity of having adequate Medevac helo assets even though I wonder if a “dedicated” asset is really what we would need at this particular moment. I mean if “dedicated” means having a flying ambulance with red cross and no other function, I really think if might be: 1. dangerous (a very nice terrorist target) and 2. not flexible and a bit restrictive (and anti-economic) at least if, like it was for us in Indian Ocean and still is on the Swedish ship that took our place in late April, it is the only helo asset present on the ship. I would rather prefer a good “designated” asset which with the technology now available can easily be done (we had a EH – 101 Helo with four stretchers and 10 seats ; on call we would go with portable ventilators, monitors, pumps etc. all devices have been tested and all have a pre arranged place to be fitted in; so it was not a flying ambulance but it did come close to it). Again, of course, this is the point of view of a “small Navy” where we cannot actually afford to have dedicated assets. All the best Andrea Tortora Capt It Navy
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claudioalp@alice.it 07/21/2010 5:22:31 AM EDT

Any difference on medical treatment must exist within army and marines. Marines need the same cures and more, for their specific activity od assault to consent other troups acts. For that reason marines must be considered as other warriors and I wish that will soon happen. Pieve di Teco, 21.7.2010 Claudio Alpaca
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Arkwood 07/19/2010 3:34:24 PM EDT

Helicopter aeromedical evac is the right of every serviceman / woman ... from all services ! Every human asset lost through inadequate evac provision is an asset lost in our quest for enduring freedom ... every life saved is an asset saved and a lesson learned in aeromedical science ! To argue against , from a cost perspective , is a cynical ignorance of the consequences of doing nothing ... as Oscar Wilde once said : ` A Cynic is one who knows the cost of everything and the value of nothing !
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edoctor 04/20/2010 12:03:21 PM EDT

The Marines are always outrageously underfunded, and underequipped but are always given the jobs that the toughest jobs and the jobs the Army is incapable of performing. Terrorists do not recognize the Geneva conventions, so the Marines do not need a helicopter that could ONLY be used for medivac. The Marines are starved too much for this luxury, but every wounded Marines deserves the best care possible. I'll be writing my congressmen.
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State-of-the-art manikins help train Marines to save lives

Contributor:  Matt Orr
Posted:  04/08/2010  12:00:00 AM EDT  |  1

Their pupils can dilate. They can replicate abnormal breathing patterns. They can bleed and even go into shock.

They can also help save lives.

That’s a lot to ask of a manikin, but the staff of the newly opened III Marine Expeditionary Force Casualty Simulation Center is confident in its state-of-the-art gear.

“They are wireless, tetherless manikins that can simulate any battle injury that we give it,” instructor Petty Officer 1st Class Jeremy Dunlap said during the final day of a recent combat life-saving course for Marines.

The SimMan 3G manikins cost $65,000 each. They are the main teaching tool at the center, which opened in September. Classes with the manikins began in February, officials said.

The center is the first in the Navy and Marine Corps to use the SimMan 3G manikins for training, officials said. The Army also uses them.

“If you give a guy in the field a [medical scenario] card, they look at you like a deer in the headlights,” said Mark Kane, an instructor who retired from the Navy after serving 25 years as a corpsman. “With this, you get a realistic training experience. This thing does it all.”

While the students are working, instructors can change the manikins’ vital signs, making the students think on their feet, Kane and Dunlap said.

“We teach the Marines the three major war wounds — [blood loss], chest injuries and airway management,” Dunlap said, explaining that a corpsman is not always available. “The course is designed to build confidence in the Marines before they have to stick their buddy.”

“The training is very realistic,” said Sgt. Jasper Ryan, who has undergone the training and will deploy soon. “It will definitely save lives on the battlefield.”

*As reported in Stars and Stripes © 2010

Matt Orr is a staff writer for Stars and Stripes Pacific and reports on important military news and events.

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US Aims To Improve Care of Military Casualties

Contributor:  IDGA Editorial Staff
Posted:  11/09/2009  12:00:00 AM EST  |  3

Just over two months ago, Air Force Technical Sergeant Michael Williams was confronted by an exploding landmine during an operation in Afghanistan.

Despite sustaining critical injuries, the explosive ordnance disposal technician managed to stand by himself for the first time just three weeks after coming face to face with the device.

His remarkable recovery is down to the treatment and rehabilitation program put in place for US military casualties, from the battlefield to the home.

"The doctors are saying I'm doing really well," Tech Sgt Williams said. "I just want to take each day slowly but surely."

Centers of Excellence

Tech Sgt Williams was initially treated at a medical facility in Afghanistan and then the day after sustaining his injuries was flown to the Landstuhl Regional Medical Center in Germany, the biggest American hospital outside the United States.

This is close to Ramstein Air Base, where many military personnel go for rest and recuperation during operations.

Less than a week after the explosion, he was then making the long journey over Europe and the Atlantic Ocean to receive treatment at the Walter Reed Army Medical Center in Washington.

Tech Sgt Williams was met by Air Force chief of staff Gen Norton Schwartz and Chief Master Sergeant of the Air Force James Roy.

"I didn't ask to meet them or anything—they were already there when I got there," Tech Sgt Williams said. "They were real nice. They asked how I was doing and everything, and made sure I was doing well."

The Walter Reed facility is one of five centers of excellence for care of military casualties, including the National Naval Medical Center's Traumatic Stress, as well as the Brain Injury Program and the Center for the Intrepid state-of-the-art rehabilitation facility and Brooke Army Medical Center Burn Center at Fort Sam Houston.

In addition, there is the Naval Medical Center San Diego Comprehensive Combat Casualty Care Center and the multi-site Veterans Brain Injury Center for patient care, education and clinical research.

Support for Military Casualties

After spending the next few weeks undergoing care in the surgery ward, still unable to walk or stand on his own, Tech Sgt Williams moved into the first stages of rehabilitation. This process can last up to a year for military casualties such as Tech Sgt Williams.

As well as this care, the Wounded Warrior program has also stepped in to support the bomb disposal expert. This scheme operates as part of an office of the secretary of defense initiative to ensure that all military casualties receive comprehensive information and guidance on benefits and entitlements.

The program begins at the point of injury for military casualties and then continues for life. An Air Force Wounded Warrior consultant at Randolph Air Force Base in Texas said that Tech Sgt Williams' progress was being closely monitored by the scheme.

Strategic Plan

Behind the facilities and initiatives supporting military casualties is the Military Health System (MHS). It received criticism for its failures in 2007, but since then it has worked hard to restore faith in standards of care for troops and their families.

The MHS has introduced a strategic plan for healthcare that includes 10 high-level strategic priorities to be delivered by 2010. This includes improving warrior care from the point of access, through active service—including deployment and treatment of military casualties—to rehabilitation and transition.

Another objective is to strengthen medical education and research. Last month, defense and Veterans Affairs healthcare professionals took part in a three-day workshop with the aim of improving psychological care for current and ex-servicemen and women.

As for Tech Sgt Williams, he believes his treatment has been first class: "Any time I need something, there's usually more than one person willing to help me with whatever it is I need or any problems, or anything," he said.

"And if it's not something they can do specifically right then, they're always willing to get someone else who can do it."

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Not so Black: Ablixa and Homicidal Side Effects

If you don’t want to know what happens in the movie Side Effects – do not read further. The post does not reveal all but does reveal important details.

So now we know Soderbergh’s movie Side Effects is not so Black/Noir after all – more Fifty Shades of Grey. Emily Hawkins (Rooney Mara) is put on Ablixa by her psychiatrist Jonathan Banks (Jude Law) and while on it kills her husband. She apparently murders him while sleep-walking triggered by Ablixa and sleep walking being a perfect defense against murder she is acquitted.

The first part of the movie is an expose of the pharmaceutical industry and greedy doctors. But in fact the industry and greedy doctors are the victims of wicked lesbians Hawkins and her former shrink, Victoria Siebert (Catherine Zeta Jones), who helps construct her alibi while both make a killing in the stock market by investing against Ablixa.

Not so Noir

Do they get away with it - I’m not telling you. Their attempt to do so though is a twist in the tale that’s supposed to be Noir.

One of the best definitions of Noir comes from the humorist Tom Sharpe, who describes an incident in the South African navy when he and colleagues were scrubbing a ship, and one of their colleagues fell overboard just as an Admiral walked up the gang plank. Everyone had to stand-to for an inspection by the Admiral, and while they did so the sailor who had fallen overboard drowned.

In real life suicides and homicides on the SSRIs have almost certainly boosted the sales of these drugs. Far from a verdict against Ablixa leading to a collapse in its share price, the publicity would have increased sales, not least among women who might want to murder their husbands.

In real life mass homicides such as school shootings even when the press in the best traditions of pantomime try to draw the attention of the cast and politicians to the drugs in the background, produce more mental health screening programs, leading to more drugs being prescribed and more school shootings. That’s Noir.

So why should an investor worry? In real life the “girls” would have lost their shirts on this one – their play should have been on the share price going up.

Antidepressants and Violence in Holland

Side Effects launched in a week that saw a Dutch court hear evidence that paroxetine (aka Aropax, Paxil, Pexeva, Seroxat, Sereupin) can cause violent behavior.

“The suspect bashed in his girlfriend’s head using a fire extinguisher and then shot a police officer. Other law enforcement officers then shot the suspect 5 times, but they still had a lot of trouble trying to restrain the suspect.

“The officers stated that they shot the suspect in the chest but it did not seem to have any effect. After the suspect had also been shot in the leg and shoulder, the suspect was still able to resist arrest. He still managed to hit another officer in the head using his gun. Officers even used pepper spray but that too did not yield any results. The officers stated that the suspect acted like a zombie.

“Court experts stated that it was highly likely that the behavior of the suspect had been caused by the use of Paroxetine”.

Why Would a Distinguished Journal Publish This?

In some jurisdictions such as Canada companies are legally obliged to say their drug can cause violence, a recent article in Psychopharmacology by Dutch academics Paul Bouvy and Marieke Liem denied the possibility of a link.

Bouvy and Liem correlated data on lethal violence in Holland between 1994 and 2008 against sales of antidepressants. The drug sales went steadily up and the number of episodes of lethal violence fell, leading the authors to claim that “these data lend no support for a role of antidepressant use in lethal violence”.

This is a marvelous example of an ecological fallacy, which is when someone claims that if an increase in the number of storks parallels an increase in the number of births that storks must be responsible for births.

Storkology

The best known example of storkology in recent years were the graphs produced by tobacco companies showing rising life expectancies and even reduced deaths from respiratory illnesses in line with rising cigarette consumption. These were produced as part of a Doubt is our Product strategy to deny the risks of smoking.

Recent sightings of storks include claims that increased SSRI use is linked to falling national suicide rates. The articles making these claims offer data from the late 1980s but disingenuously omit some key facts. One is the fact that suicide rates in most Western countries were falling before the SSRIs were launched. Another is the fact that both suicide rates and antidepressant use rose during the 1960s and 1970s when antidepressants were being given to the most severely ill people at the greatest risk of suicide. This was when suicide rates should have fallen if antidepressants have any effects on national suicide rates (Reseland et al 2008).

Autopsy (post mortem) rates are also left out. The more autopsies done the more suicides and homicides are detected. Autopsy rates rose in the 1960s and 1970s and fell from 1980 before antidepressant consumption began to escalate dramatically. The rise and fall in autopsy rates perfectly mirrors the rise and fall in suicide rates (See Reseland et al 2008).

Why not the Same Argument for Alcohol and Violence?

Why would Psychopharmacology, a prestigious journal, take an article like this?  Alcohol use has increased in Holland during this period but no-one is making the argument that increased alcohol use has led to a decline in acts of lethal violence or the further Bouvy and Liem argument that this means alcohol cannot cause violence.

SSRIs slow growth in children. During this period SSRI consumption among children has increased in Holland but the Dutch have become the tallest people in the world and are getting taller. Where is the article saying that the increasing height of the Dutch proves that SSRIs don’t retard growth?

In the case of violence, the published trials show antidepressants cause it, at a greater rate than alcohol, cannabis, cocaine or speed would be linked to violence if put through the same trial protocols that brought the antidepressants on the market.

And there is at least one clear and well-known factor, just like autopsy rates that can account for the findings – young men. Violence is linked to young men, and episodes of lethal violence are falling in all countries where the numbers of young men are declining.

Antidepressants and School Shootings 

School shootings were almost unheard of before the SSRIs appeared on the scene. Correlation is not causation but in between this and the next blog post I will be laying out the evidence that antidepressants cause violence up to and including homicide at two lectures in Chicago - including the evidence that real life antidepressants as opposed to Ablixa can in fact cause sleep walking and murder. A video of the lecture will be posted on RxISK.org as soon as possible afterwards.

You and your meds. Give the real story. Get the real story.

Pharmaceutical companies have hijacked healthcare in America, and the results are life-threatening.

 

Dr. David Healy documents a riveting and terrifying story that affects us all.

 

University of California Press (2012)

 

Available on Amazon.com

 

View the original article here

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101 uses for a Dead Journal

There used to be a wonderful cartoon series called 101 Uses for a Dead Cat, which led me 25 years ago to give a talk at a British Association for Psychopharmacology meeting entitled 101 Uses for a Dead Psychiatrist. That was back in the days when Psychopharmacology meetings were places of debate and the British Journal of Psychiatry was guaranteed to have something of real interest in every issue. Under a series of editors the Journal was so good that it still inspires affection in the likes of me and an older generation of psychiatrists – worldwide.

Perhaps as a legacy of those times, the British Journal of Psychiatry now runs an interesting little corner in which they invite authors to distill the essence of an issue into 100 words.

This isn’t as easy as it might sound. It’s like composing a haiku or limerick or tweet – if you’re not used to it, it takes time to get the balance right especially when they invite you to write 100 words on Psychiatry and the Pharmaceutical Industry, as they asked me 3 years ago.

After a lot of revisions, this is what I ended up with.

Little Pharma made profits by making novel compounds; Big Pharma does it by marketing. Doctors say they consume (prescribe) medication according to the evidence, so marketeers design and run trials to increase a drug’s use. They select the trials, data and authors that suit, publish in quality journals, facilitate incorporation in guidelines, then exhort doctors to practice evidence-based medicine. Because “they’re worth it”, doctors consume branded high cost but less effective “evidence-based” derivatives of older compounds making these drugs worth more than their weight in gold. Posted parcels meanwhile are tracked far more accurately than adverse treatment effects on patients.

As it turns out, here was a manifesto for RxISK before RxISK was a glint in anyone’s eye. The journal accepted it without demur.

But the climate had been slowly changing with the chill spreading from the heart out to the extremities as happens in the most serious conditions. The journal has been getting a lot less interesting. There are few people I know who confess to reading any of its seemingly evidence based pieces.

I had already had a problem when asked to do a book review – 300 words. Again difficult to distill the essence of an important and complex book like The Loss of Sadness into 300 words. I was pleased with the outcome but the journal wasn’t and approached someone else to provide a review. I thought about protesting but let it pass – this will be a future post.

I was then asked to review one of these in all probability ghostwritten evidence based pieces, an article comparing escitalopram and venlafaxine. This article had a heavy sprinkling of the flaws found in pharmaceutical company trials outlined in Ben Goldacre’s Bad Pharma. I pointed out a number of them and gave a view that the piece was close to worthless – but that the editor might try an interesting experiment. Why not ask the company to post the full dataset linked to this trial in exchange for the privilege of posting in the British Journal? He either never had the nerve to ask the company or else was rebuffed and nevertheless went ahead and published.

Then on September 20th came an invitation to write another 100 word piece – on Antidepressants. It took more than 6 weeks before something took shape. When it did after some polishing I finally felt happy.

Isoniazid, reserpine, imipramine, atropine, stimulants, benzodiazepines, antipsychotics, fluoxetine, ketamine – all have antidepressant credentials. The word coined by Max Lurie has lost meaning; it’s a basket for acronyms. Psychiatry was the first branch of medicine to have specialist hospitals and journals, the first to adopt controlled trials, rating scales, and guidelines. The antidepressants beckoned us toward clinical neuroscience but have led to myth, hidden data, ghostwriting, more lives taken than saved, womb to tomb consumption, and an increased incidence of “depression” from 1 per 1,000 to 1 in 5 of us. Knowing when not to prescribe is the greatest art in medicine.

The response was:

Dear David

Thank you, that’s excellent. I will show it to the Extras Editors for review and will get back to you with their decision.

A week later it was:

Dear David

The Extras Editor has reviewed your 100 words and is happy with it generally, but has some reservations concerning the phrase ‘more lives taken than saved’ – would it be possible to tone it down or omit it altogether? The Editor feels that 100 words is not a good place for a polemic and that we should present a consensus view held by the profession in general, which may not pertain to this particular phrase…  One other thing is that all the drugs mentioned in the text but Prozac are referred to by their generic names, shall we call it fluoxetine for consistency?

I responded:

Dear

I can happily concede the switch from Prozac to fluoxetine but ‘more lives lost than saved’ is a completely evidence based position – I can provide all the data for this. It would simply not be possible to say the opposite. I didn’t think these pieces were aimed at giving a supposed consensus view – I had assumed they must inevitably be viewed as somewhat idiosyncratic.

[For the record the entirety of the placebo controlled trials database on antidepressants (over 100,000 subjects) shows an excess rate of deaths on antidepressants compared to placebo].

To which the reply on December 18th was:

Dear David

I hope you are well. I am afraid I don’t have good news regarding your 100 words on antidepressants. The Editors have deliberated further on whether to publish it and decided they could not, unfortunately, publish it in its current form. We are very sorry for this outcome and are grateful for your time and efforts.

Wishing you a Merry Christmas and a bountiful New Year.

Almost anyone I know who goes to the United States these days is astonished by the level of fear there among anyone working in the mental health field – fear to express any criticism about drug therapies, a fear to lower doses, or reduce treatment cocktails from 5 or 6 drugs to 1 or 2. The land of the free and home of the brave seems anything but these days.

Things feel better than this in Britain but there is all the same a marginalization of “dissent” and a greying of the landscape. The British Journal of Psychiatry has become exceedingly grey – although its current edition has an opinion piece by Pat Bracken and colleagues.

Twenty-five years ago friends from North America thought Britain was in decline. They remarked how the country couldn’t even afford to mow the grass that grew on the verges of or in the central reservations of motorways. The place was looking scruffy.

No, no I told them it’s a really clever idea. The country was being so intensively cultivated elsewhere that there was a real risk of a loss of biodiversity and letting strips of meadow flourish in the margins of motorways was a creative use of this land. Most of them I’m sure didn’t believe me – some of them I know didn’t.

Britain still has flourishing meadow grasses and plants along its motorways, but its academia it seems cannot allow anything slightly “wild” to grow in the interstices of their journals.

This is at a time when the editors of major British journals in particular see fit to use their journals as a pulpit to pontificate (offer their personal non-consensus views) on issues, while at the same time increasingly denying other voices.

Perhaps we should give up the pretense that this is a Collegial Journal, a journal for Fellows and Members. Where’s the collegiality in getting missives from nameless Editors relayed through someone even though she was quite delightful.

The current Editor in Chief started his term of office by saying he was proud that the British Journal of Psychiatry published articles like that by Healy and Cattell on Ghostwriting in Medical Journals. While the current edition has a call to action by Bracken and colleagues, it also has one by Arthur Kleinman that refers to the need for a Global Mental Health movement. This is certainly a well-intentioned piece but probably offers one of the best examples there is of the capture of evidence-based-medicine by the pharmaceutical industry of which more in the New Year.

It was the “Merry Christmas” what did it.

You and your meds. Give the real story. Get the real story.

Pharmaceutical companies have hijacked healthcare in America, and the results are life-threatening.

 

Dr. David Healy documents a riveting and terrifying story that affects us all.

 

University of California Press (2012)

 

Available on Amazon.com

 

View the original article here

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The boy with the ponytail who played with fire

He is 6’4” at least – 192 cm. He has blonde hair tied back in a ponytail. When he first suggested making a program about SSRIs I was not very helpful – very little of the media coverage by 60 Minutes or anything else has ever seemed to make much of a difference. They may have just increased the sales of antidepressants by keeping the names of the various drugs in the limelight. And he was suggesting more talking heads which the cutting edge of journalism tells me is past tense.

But he was persistent and turned up on my doorstep, putting himself up in a very cheap hotel, because as I found out later he had almost no money. Many of the people I put him in touch with as he and his son Elias wound their way literally around the world making their program were far more generous than I in accommodating them in their own houses.

Who is He?

Who was he? He is Swedish and his wife Mexican – a striking genetic and cultural mix. She makes wrought-iron jewellery. He had been a classical musician but had decided orchestral living was not for him. This had led him to film-making. But finding work was difficult.

He was gifted. Seeing him edit the huge volumes of material he amassed, produce graphics to illustrate points and carve out a distinctive story line all in the apartment in Stockholm in which they lived – you couldn’t but be impressed. This was a far cry from BBC or CBS or CBC or NBC studios. When I went to visit him in Stockholm, the American version of The Girl with the Dragon Tattoo had just come out and it was difficult not to think of Lisbeth Salander.

Swedes would listen he said. He knew his countrymen and women. They still believed what they heard on the news and read in newspapers and they just needed to be told the truth up front. This didn’t seem completely naïve to me, Swedes are a bit like this. I was certain the rest of the world wouldn’t listen but if one country really did take the message on board who knows…

Who Cares in Sweden?

The central idea was all his. He and Elias both had friends who were put on an SSRI who had lost their personalities.  The drug produced a lack of caring that had spreading consequences for everything. Both had lost friends and families. But no-one said anything.   Jan talked to eight doctors about it and they all told him he was wrong, “the medicine did not have these effects”.  Finally he talked his friend off the medication and his personality was reborn.

If the doctors instead had answered:  ”That was interesting, I will keep that in mind.”  … then he probably wouldn’t have started the project.

He ended up coming to me because he began by asking Swedish doctors to participate in the film and noticed that almost all said no. It would be too dangerous for their careers to be involved. He was regularly asked by doctors and politicians and others if he belonged to the Scientology Church. This puzzled him as he knew nothing about Scientology. He was also not anti-medication – several family members had been greatly helped by medicines.

Slowly he came to the view that Swedish journalists didn’t talk about the obvious corruption in Sweden because they didn’t care about the issue.  For Jan the idea that a great deal of money from the pharmaceutical companies is being used to corrupt society is a non-starter as an explanation.

This is the case even though doctors are being corrupted. As he puts it “there is money that is being distributed as cash in small envelops,  hand-to-hand or as repayment for consultant missions. The money can also be found hidden as funds for research or equipment or as invitations for doctors and journalists to international meetings. These offers are mostly sponsored by the pharmaceutical industry –  all kinds of “services” seduce the recipients.

“Doctors end up getting trapped. On return home their colleagues never find out what really happened. They show their respect or feel envy for their colleagues who receive higher salaries, reputation and influence. Only a few people in Sweden acknowledge today how bad the situation is. Ignorance is massive”.

“That’s why we had to travel to foreign countries in order to find people willing to speak to us. As individuals we can’t make big changes or tell politicians, journalists or the justice system what to do. But as a production company, we are definitely able to produce films that may be helpful for society. There are many people searching the Internet for information about side effects that doctors have been taught to deny”.

Swedish Catatonia

I knew nothing about his views when we met first. I was struck by another idea of his. If the treatment could produce something like this in his friend, there seemed to him to be no end to the implications. Would any of the contracts his friend might have entered into during this period, from business contracts to relationship contracts, to legal contracts, to property deals be valid? Were the contracts anyone entered into while on these medicines – stockbrokers, bankers, lawyers – valid?

The more he explored the more he found firemen who were aware of the effects on them or on those who had set fires by accident or on purpose, judges who were aware of the effects within the legal system, doctors treating children who knew of the effects – all of whom facing the problem turned mute and were paralyzed.

There is a condition called Catatonia that can be induced in animals by facing them with tasks such as having to distinguish between an oval and a circle in order to get a reward. As you gradually start making the oval more circular and the circle more ovoid, the dog or other animal gets distressed and finally freezes.

We can cope with judgement calls about responsibility when people who are normal do things and when people who are on an LSD-trip do something – especially if the person has been slipped the drug without knowing it. When someone in the midst of an LSD trip steps out of a twenty-fifth floor window, we do not regard this as suicide. LSD works on the serotonin system. Start making it harder to distinguish between normal and treated serotonin systems and both people and Society freezes up.

A Norse Myth

I felt I was being educated about the drugs by someone who had no background in the issues. It was a story that definitely needed to be made if only because it has the dimensions of a Greek tragedy or myth.

The SSRIs are after all a Swedish invention. Arvid Carlsson who later won a Nobel Prize produced the first SSRI, zimelidine, 3 years before Prozac was made. Carlsson deliberately made an SSRI whereas Lilly only produced one as an accidental by-product of a search for a quite different drug. Zelmid was also brought to the market in 1981, 7 years before Prozac. See Let Them Eat Prozac for a history of what happened next.

Can antidepressants and even Zelmid cause suicide? According to Carlsson in 2000 yes – “we have known this for a long time”.

But it doesn’t stop there, Stockholm is of course the place where Stockholm syndrome was born.

In August 1973, a bank robbery at the Kreditbanken in Stockholm triggered a 5-day siege with bank employees held hostage. The media camped outside. After the siege ended, to the surprise of everyone many of the hostages, as if hypnotized, spoke well of their captors.  “Stockholm syndrome” was born. Now recognized as common, the conditions that trigger this change in behavior seem to be isolation, a fear that your life is at risk and kindness on the part of the hostage takers.

Disease isolates us as profoundly as incarceration or anything else might. Our lives are at risk, and our doctors who control the exit to freedom are almost certain to be kind. But not a single doctor is trained to manage Stockholm syndrome, to suspect that apparent insouciance or congenial conversation might conceal deep unhappiness with a proposed course of treatment or worse again alarm at new problems that have emerged on treatment.

Doctors are also increasingly likely to suffer their own Stockholm syndrome. If something goes wrong with a treatment a doctor gives, even though the label may concede that the drug can cause the problem, the makers of the drug and other doctors will deny that it is likely to have done so in any particular case. Speaking up about a problem, once the material of medical advance, is now a recipe for professional suicide.  A doctor attempting to rescue a patient is likely to be accused of being a persecutor who takes patient hostage by withholding effective treatment.

Offers to describe problems at professional meetings are turned down. Journals are ever less likely to accept publications outlining a new problem. Invitations to apply for better jobs, to attend conferences, or simply to go with colleagues to local eateries funded by drug companies are ever less likely to happen for doctors linked to adverse events. Those holding doctors hostage have been very kind indeed – there are ever fewer medical departments or medical conferences not awash with company support, when it comes to paying for meals with colleagues most doctors have forgotten what a credit card looks like, and of course in supplying drugs they supply the objects that make doctors desirable.

What can a Hobbit do?

“We all must take advantage of freedom of speech and freedom of press. This is what the small individual can do in a democracy. Thereafter it’s up to the professional journalist and politician to act. The truth is that Sweden needs help from foreign politicians, scientists and journalists. It is very sad to have to admit that many homicides, school shootings and other horrible killings are linked to medication and that this fact is being suppressed as journalists exclusively talk about weapons”.

“Many people decide to stop their medication when they start getting the “numb feeling” or the “derealisation feeling”. However, in the majority of cases, doctors insist they continue until the side effects “disappear”.

So Jan Akerblom made Who Cares in Sweden.  This is playing with fire. He has taken on the Swedish establishment for real. Lisbeth Salander is the myth, Jan Akerblom the reality. See this link.

“Our conclusion is that, the best advice, in order to clarify any problems is to talk to the person’s family, friends and colleagues. The person themselves may not be aware of the side effects, the change of personality, the problems he or she creates . People sometimes say that the ”medicines work” precisely because they just don’t care anymore”.

This conclusion about what he had to do and also what needs to be done to clarify individual problems are exactly the conclusions that Rosie Meysenburg came to that led her to create SSRI Stories.

In the next post, we’ll see some of the consequences of Kicking the Hornet’s Nest.

You and your meds. Give the real story. Get the real story.

Pharmaceutical companies have hijacked healthcare in America, and the results are life-threatening.

 

Dr. David Healy documents a riveting and terrifying story that affects us all.

 

University of California Press (2012)

 

Available on Amazon.com

 

View the original article here

Read More

The Shipwreck of the Singular

Crusoe’s first appearance was in The Creation of Psychopharmacology, where in recognition of the tensions inherent in medicine between the numerous who enter clinical trials and the single person being treated by a doctor, the book opened with a quote from George Oppen’s Of Being Numerous, in which he notes that: “Crusoe we say was rescued”.

Since Oppen wrote these lines, the idea of the perfect ultra-short story has caught the imagination of many. Competitions have been run in an attempt to equal or surpass Hemingway’s 6 words:  “For sale: baby shoes, never worn.”

“Crusoe we say was saved” is only 5 words and is not just a story but one with a perfect post-modern twist.

Crusoe deals in ambiguity – how apparent progress can give rise to new problems or even new evils. You will hate her if you are the kind of person who thinks good intentions the most important thing there is. She lives in a world in which as Gandhi put it: “He who would do a great evil must first of all persuade himself he is doing a great good”.

Sometimes its better to be less certain.  And here a mythic image can unite us in the way that holding hands in the dark can.  To check out who you’re holding hands with, Crusoe appears in Watch where you wave that wand, The Oedipus Effect, The Tree must go and Data Access Wars, but her spirit is also present in Randomized God, If Pharma made cars, May Fools’ Day and One Script to rule them all .  She will appear again in a companion piece on January 1st – The girl who wasn’t heard when she cried wolf.

The Pharmageddon Three

Pharmageddon is about how three obviously good things we did to manage the pharmaceutical industry (for its own good of course) have given rise to the increasing threat that modern medicine poses to our safety and sanity.

1/         Making clinical trials mandatory for regulatory purposes. This was supposed to keep us safe in heavenly health by forcing the financial camel that is the pharmaceutical industry to squeeze through the eye of a scientific needle. But harnessing trials for this purpose has transformed their role from one of puncturing therapeutic bubbles into one of providing the fuel for therapeutic bandwagons, and has degraded them from scientific experiments to a mechanical exercise adapted to the convenience of bureaucrats.

2/         Prescription-only status for new drugs. This regulation aimed at bringing hazards to light and protecting vulnerable patients but is now a means whereby the major hazards of new drugs take 10-15 years to come to light and it is only after campaigns by injured patients that doctors ever concede there might be a problem. Doctors have become a risk-laundering system. Thalidomide might still be on the market if it had been prescription only.

3/         Rewarding companies with product rather than process patents for drugs. We have, possibly accidentally, over-rewarded pharma. Or product patents may have been a deliberate move by the United States to capture the European pharmaceutical industry. At a time when medicine has been captured by pharma, and doctors have been hypnotized to focus on clinical processes rather than clinical outcomes, patents might ironically be the one place in medicine where the process should be the outcome.

Crusoe’s other conundrums

1/         Eurordis. It sounds like a wonderful idea to form an organization for patients with rare diseases who would lobby Pharma to do something they didn’t want to do namely to focus on rare conditions for which the market returns might have seemed slim. But Eurordis and other rare disease organizations have now become one of Pharma’s most treasured conduits. These groups can be depended on to take Pharma’s side even though very little money changes hands – See Data Access Wars and Access to clinical trial data.

2/         Ownership of clinical trial data. It might seem like a good idea to have patients own their own data but ownership in this sense is a Trojan Horse. If you own something you can sell it and this will kill science. Imagine someone coming along to a scientific experiment who was only willing to let their piece of apparatus be used to find out what the universe is made of if an appropriate fee is paid beforehand.

It is not clear who owns clinical trial data. If pharmaceutical companies do not own it, the only proper course of action is, companies will say, to make the patient the owner. This sounds almost benevolent except it will transform patients into livestock at an auction.

3/         Eliminating chance through statistical significance testing – reliable analyses is what the pharmaceutical industry call this –  sounds like a good idea. But rather than producing reliable knowledge, claiming we only know something when the findings are statistically significant in fact induces a psychosis, causing both doctors and patients to discount the evidence of their own eyes. A reverse Macbeth problem – “I see no weight gain or muscle wasting or heart attack before me”.

4/         Quality improvement. We should monitor what doctors do – everyone can improve their performance. Having someone stand there with a tickbox to monitor what is happening in clinical care sounds like a good way to produce steady improvement.  In fact in close to 100% of cases the process becomes the outcome. And as the quality of the process improves the quality of the outcomes deteriorates.

There is no better way than this to transform doctors into factory doctors.  Set a target they should meet – screening 80% of patients who have asthma and pretty soon the relationship of doctor to patient will be changed from one in which you consult your doctor when you have a problem to one in which your doctor will summon you to be screened and tell you you have a problem even though you might feel perfectly well.

5/         Outcome data. Doctors should monitor what in fact happens when they do things. Mortality should be low and there should be little variation between centres. But if the treatment is one that shouldn’t be done, as in the case of hysterectomies or giving statins for primary prevention of cardiovascular disorders you can have perfect mortality statistics and almost no variation across centres but a disastrous outcome.

The best example of this are  recent approaches to mandatory vaccination for influenza and other disorders in which rather than count outcomes such as the number of living and dead in those vaccinated or not, quality services are determined by compliance with policy. If everyone is vaccinated the outcome is deemed good, whether or not there are more dead bodies.

6/         Reporting adverse events to regulators. Companies increasingly encourage people and doctors to report adverse events to FDA. This sounds marvelous and something like turkeys voting for Xmas. But in fact companies advocate this deliberately because they have a legal obligation to follow up reports to see what happens to patients whereas FDA don’t. This demonstration of corporate responsibility is in other words a way to transform drug induced injuries into anecdotes with no legal or policy implications. Unbelievable though it sounds this is the most devious and best way ever devised to hide the data - as the American Woman story demonstrates.

7/         Drawing up standards of care – guidelines – will help shield us from rogue doctors. In fact guidelines – especially the most independent guidelines – have become the greatest marketing tool for the pharmaceutical industry who have learnt how selective publication and creating new disease indications can capture a guideline completely. Guidelines then become a threat to the future employment of doctors practicing a medical care that is at odds with what pharmaceutical companies wish. In the United States at present, certainly within the mental health field, they have produced an extraordinary fear and paranoia with doctors unable to contemplate reducing medication in either number of different medications or dose.

There are two ways in which guidelines might work. One is a set of guidelines that outline treatments that should not be given. The other is a set of guidelines that outline where data is missing – that outline what we do not know rather than outline what it is pretended we do know. The Data Based Medicine Guidelines on dopamine agonists, antidepressants and mood stabilizers attempt to do this.

8/         In clinical trials, we should protect patient privacy and confidentiality. This sounds wonderful until placed in informed consent forms where it means, pharmaceutical companies will hide your data for ever.

9/         Medical staff should undertake ongoing educational assessment to remain up to date, and should demonstrate this openly to the public. The intention here is that doctors should have a real and continuing engagement with science.  But this is not measurable. The outcome will be a series of boxes to be ticked that get in the way of doctors asking real questions. Because industry do box ticking better than anyone else, this is guaranteed to hand healthcare professionals over to the marketing departments of pharmaceutical companies or their surrogates.

10/       Doctors should stick to what FDA approve and should not prescribe off-label.  If my roofer put an unapproved material on my roof I would be furious. But the so called approval process for drugs is about approving the wording of advertisements – it is not about setting standards for treatments that work nor is it about regulating the practice of medicine. The most effective treatments in medicine are off-label.  SRRIs are much more effective for premature ejaculation than for depression.

Forcing doctors to prescribe on-label would hand over medicine to the pharmaceutical industry. As it is doctors are increasingly scared to prescribe off-label – as they come more and more under the control of Sauron’s Eye. As Tom Laughren might have said but didn’t quite, doctors need to Man Up

11/        Everything would be okay if doctors just declared their conflicts of interest. The trouble here is we want doctors to be biased toward treatments that work and the best possible evidence. Someone with no conflicts of interest might be nice to go and talk to but if I need something done this kind of person is not going to be much use to me. The problem with doctors and conflicts is that they have lost sight of the fact that they can’t prescribe the best rather than the latest and the fashionable if they don’t have access to the data, and if they can’t stand up to pharmaceutical companies they have no brand value. They are like salt that has lost its bite. (Model doctors, Scaremongers of the world unite, So long and thanks for all the fish).

12/       The Mencken paradox. Most of these perversions arise from efforts to find solutions to problems – which suggests that the insoluble problem is our need to have solutions. Solutions end up being problems.

To adapt HL Mencken; “Every complex problem has many simple solutions – all of them wrong”.

Chuang Tzu

Or as Chuang Tzu put it in 323 BC;

“For security against robbers who snatch purses, rifle luggage, and crack safes, one must fasten all property with ropes, lock it up with locks, bolt it with bolts. This is elementary good sense. But when a strong thief comes along he picks up the whole lot, puts it on his back, and goes on his way with only one fear; that ropes, locks and bolts may give way.”

On Fridays

The unsolvable problem medicine faces is that each of us is shipwrecked in the singular. When on a Friday running from a threat to our life we seek refuge in Crusoe’s clinic, we have to hope that a basic humanity asserts itself. We have to hope that Crusoe has not been trussed in guidelines, and quality improvement programs, and that she is not being slowly cooked in a management pot. We have to hope that she is not part of a system in which cruelty has been normalized – as Ann Clwyd put it so devastatingly a few weeks ago.

We have to hope that Crusoe has not been saved. If snatched away, those of us who turn up on Friday will have to mount the mission to rescue her.

Illustration: Shipwrecked by the Cure, 2012 © Billiam James

You and your meds. Give the real story. Get the real story.

Pharmaceutical companies have hijacked healthcare in America, and the results are life-threatening.

 

Dr. David Healy documents a riveting and terrifying story that affects us all.

 

University of California Press (2012)

 

Available on Amazon.com

 

View the original article here

Read More

Prozac and SSRIs: Twenty-fifth Anniversary

One Prescription for Every Man, Woman and Child

Prozac was approved in 1987 in the US, and launched in early 1988, followed by a clutch of other SSRIs. Twenty-five years later, we now have one prescription for an antidepressant for every single person in the West per year.

Twenty-five years before Prozac, 1 in 10,000 of us per year was admitted for severe depressive disorder – melancholia. Today at any one point in time 1 in 10 of us are supposedly depressed and between 1 in 2 and 1 in 5 of us will be depressed over a lifetime. Around 1 in 10 pregnant women are on an antidepressant.

No one knows how many new cases of depression there are per year partly because modern depression is a creation of the marketing of Prozac. Until recently what is now called depression was called anxiety, nerves or a nervous breakdown. SSRIs can help some cases of nerves but they are of no use for depression proper – melancholia. But the money for companies lies in treating nerves not melancholia – and as a result any of us with severe depression is likely to get worse treatment now than we once did.  We’ve gone backwards.

How Many Hooked?

By 1999 the number of us taking SSRIs chronically equaled the number starting an SSRI each year. By 2003, over 6 million Americans were taking an antidepressant semi-permanently – along with over 6 million Europeans.

The number of prescriptions for antidepressants is increasing by 5-10% each year, while the figure for people starting each year remains the same. This means that there is an increase of 5% to 10% in the number of people hooked to antidepressants each year.

Lives Lost

There is no research evidence to suggest that anyone’s life is saved by taking an antidepressant but if there are lives saved the research makes it clear that for every life saved there must be another lost. There are probably something between 1000-1500 extra suicides in the US each year, triggered by an antidepressant – an extra 2000 -2500 in Europe.

The data is similar for violence. There are probably between 1000- 1500 extra episodes of violence in the US each year that would not have happened without antidepressant input and between 2000-2500 extra episodes in Europe.  Some of these will include school or other mass shootings which were unheard of twenty-five years ago.

Aborted Families

About 4000 families in the US have children born with major birth defects each year because of antidepressants taken in pregnancy. Up to 20,000 women per year have a miscarriage because of these drugs and a large number have voluntary terminations linked to antidepressants. Miscarriages are among the biggest single predictors of later mental illness and substance misuse in women.  In Europe these figures likely run at an extra 6000+ birth defects, 30,000+ miscarriages, and who knows how many extra voluntary terminations.

Most children born to mothers who have been on these drugs do not have obvious birth defects. But it increasingly looks as though these children may show cognitive delay and other autistic spectrum features.

The Dead Doctor Sketch

Perhaps the greatest casualty of Prozac has been holistic medicine. Imagine you have numbness in an arm or pain in a shoulder. If referred to an orthopedic or neurology department you will have every conceivable scan or test to pinpoint the problem. Chances are the clinic will find abnormalities and attempt to put things right – abnormalities that are not the source of your problem. A good generalist, who knows your circumstances, relationships, difficulties at work and the community from which you come, can spot when aches and numbness stem from strain or tension – they see you rather than bits of you.

Prozac has killed Generalism. It did so by focusing attention on mood in the way neurologists hyper-focus on nerves. Psychiatrists have become the doctors who deal in heroic combinations and doses of pills rather than doctors who, like generalists, step back and take a broader view.

Prozac has also killed therapy – just like Prozac CBT has a hyper-focus on thoughts rather than the big picture. CBT has also become a conduit into antidepressant prescribing as therapists regularly suggest softening up a depression with pills.

Psychiatry leads the Way

Many see or saw psychiatry as a medical backwater with grim, overcrowded hospitals, and a dim understanding of the disorders it treats. In fact it was the first branch of medicine to have specialist hospitals and journals, the first to discover the bases for and eliminate several serious disorders, the first to adopt rating scales and controlled trials. And with Freud’s son-in-law, Edward Bernays, it was the first to step into public relations.

Twenty-five years ago, no one could have imagined that the bulk of the treatment literature would be ghostwritten, that negative trials could be portrayed as glowingly positive studies of a drug, that controlled trials could have been transformed into a gold-standard method to hide adverse events, or that dead bodies could have been hidden from medical academics so easily.  Twenty-five years ago no one would have believed that a drug less effective for nerves or melancholia than heroin, alcohol or older and cheaper antidepressants could have been brought on the market and that almost as a matter of national policy people would be encouraged to take it for life.

You and your meds. Give the real story. Get the real story.

Pharmaceutical companies have hijacked healthcare in America, and the results are life-threatening.

 

Dr. David Healy documents a riveting and terrifying story that affects us all.

 

University of California Press (2012)

 

Available on Amazon.com

 

View the original article here

Read More

Media coverage

Dr. David Healy is an internationally respected psychiatrist, psychopharmacologist, scientist, and author. A professor of Psychiatry in Wales, David … [Read More...]

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