As reported yesterday, the Nevada State Board of Medical Examiners disciplined a record number of doctors at its last meeting.

The Board has come under scrutiny in recent years for a variety of practices. In fact, according to a Reno Gazette Journal article dated December 12, 2007, our Nevada Board is one of the worst in the United States for disciplining doctors.

A Reno Gazette Journal inquiry found that the Board misrepresented information regarding the discipline of doctors, ignored a number of complaints against doctors with other malpractice instances, and did not hold Nevada doctors to high standards.

A watchdog group founded by Ralph Nader, Public Citizen, ranked Nevada's Board at 47th in the nation for doctor disciplinary action, down from its ranking of 40th in 2002.

As reported yesterday, the Board recently disciplined seven licensed doctors and a physician's assistant at a quarterly meeting, which was the largest number of disciplinary actions at one meeting in the last several years. It also has an additional 600 cases pending review.

All eight of the medical professionals disciplined were from Southern Nevada, which accounts for more than two-thirds of the state's doctors.

According to the Reno Gazette Journal Article, the professionals disciplined at the meeting include:

Gregory Bryan, M.D.: Bryan was disciplined for administering a drug in a way not authorized by law, the board said. Bryan also failed to properly supervise a physician assistant who was allowed to administer the drug, despite knowledge that the drug wasn't approved by the U.S. Food and Drug Administration. Bryan has been placed on 12-month probation and isn't allowed to inject, prescribe or personally use any cosmetic substances. Bryan also needs to complete a continuing medical education on charting and ethics and must pay a $1,000 fine. Failure to meet any probation terms will result in a 30-day license suspension.

Michael Sullivan, physician assistant: The terms of Sullivan's discipline basically is similar to Bryan's, except his fine is $500.

Gilles Desmaires, M.D.: Voluntarily surrendered his license while under investigation by the board.

David Linden, M.D.: Violated Nevada statutes for having an Oklahoma license that had been suspended, modified or limited. Linden's license has been suspended for 120 days. The suspension will be stayed under the condition that Linden be placed on probation for two years.

Stuart Steele, M.D.: Steele had his license revoked after being found guilty of unlawful possession and distribution of a controlled substance and also conspiring to possess and distribute controlled substances.

Theodore Thorp, M.D.: Thorp received public reprimands for two separate cases. The first involved malpractice for failing to use reasonable care, skill or knowledge in treating a patient. The second case involved failure to keep complete medical records and lack of proper informed consent. Thorp also was ordered to complete an in-resident Internal Medicine Board Review Course and continuing education on medical record keeping.

Sidney Van Assche, M.D.: Van Assche was found in violation of Nevada statutes concerning the inability to practice medicine because of illness, a mental or physical condition, or the use of alcohol, drugs, narcotics or any other substance. The board ordered Van Assche's license revoked, with the revocation stayed for five years upon compliance with probation conditions.

Jozsef Zority, M.D.: Received a public reprimand and was fined $5,000 for failure to keep accurate and complete medical records.

In the most recent Nevada Board of State Medical Examiners meeting, seven medical doctors and one physician's assistant were disciplined.

The Reno Gazette reports that this is the largest number of disciplinary actions at one meeting in several years.

Professionals disciplined include: Gregory Bryan, M.D., Michael Sullivan, P.A., Gilles Desmaires, M.D., David Linden, M.D., Stuart Steel, M.D., Theodore Thorp, M.D., Sidney Van Assche, M.D., and Joesph Zority, M.D.

Violations range from improper administration of drugs to possession and distribution of controlled substances.

Check my blog tomorrow for more information.

Ah the new and complicated world of how email production is handled by courts.

Scott Roseland, at cybercontrols (www.cybercontrols.net), cites to Benton v. Dlorah, Inc., 2007 U.S. Dist. D. Kan, Oct. 30, 2007. There, the plaintiff informed defendant at her deposition that she had deleted e-mails, and defendant filed a motion to compel plaintiff to produce relevant documents, to produce her hard drive, and for sanctions for spoliation of evidence.

Initially, the court ruled that the requesting party (defendant) had not adequately shown that the requesting party had refuted producing party's (plaintiff) assertions that she had produced all relevant documents, but allowed requestor to amend if further discovery demonstrated that producer had not produced all documents or "had spoliated relevant evidence." Id. at *3-*4.

On their subsequent motion to compel, requestors asserted that producer had admitted failing to produce a relevant e-mail, that she used her personal account instead of her work e-mail and admitted deleting "hundreds" of possibly relevant e-mails. Producer responded that requestor's request was not sufficiently tailored, that her personal computer contained personal and privileged information, and that the request constituted a "fishing expedition", not outweighing the harm to her.

The court ruled that producer must produce the relevant e-mails, which were responsive to requestor's request.

Deleting these e-mails, even if done in good faith and at a time before Plaintiff contemplated her legal action, does not necessarily remove the e-mails from her possession, custody or control. Deleted documents should be retrievable from her computer system and thus remain within in her control.

Id. at *7. The court ordered that if she could not produce the e-mails, "she shall produce for inspection her computer hard drive from which the deleted e-mails were sent. This will allow Defendants to use the services of a computer forensic specialist, if necessary, to retrieve them." Inspection of the drive would be limited to the subject of requestor's request. Id.

The court made no reference to any distinction between accessible and inaccessible data. In effect, deleted e-mails may now have moved into the realm of "accessible" data.

There is and will continue to be lack of uniformity in the way that courts handle production of email and other electronic data.

Antidepressants are again under scrutiny.

According to a Yahoo! News Article dated December 18, 2007, the Supreme Court will hear a case regarding a teen, Christopher Pittman, sentenced to 30 years of prison for killing his grandparents and setting fire to their home at age 12.

His attorneys argue that the lengthy sentence violates the teen's Eighth Amendment protection from cruel and unusual punishment. They claim that this is the only case in the country that gives such a harsh punishment to a minor.

This case is most noted for its association with the drug, Zoloft. I n the original trial, Pittman's attorneys unsuccessfully tried to argue that the drug influenced their client.

According to an August 24, 2004 New York Times article written at the time the original case was pending, most medical experts do not believe in a link between antidepressants and acts of extreme violence and aggression.

Pittman claimed that something told him to commit the murders and that he was feeling isolated and aggravated a few days after starting the drug. Conversely, his doctor's notes about his behavior state that he was energetic and had no plans to harm himself.

The article also makes note of two other cases with similar fact patterns. In 2001, the drug company, GlaxoSmithKline, the maker of Paxil, paid $6.5 million to the relatives of a man in Wyoming who killed his wife, daughter, granddaughter and himself. This was the first time that a jury concluded a SSRI-type of antidepressant may lead users to suicide or homicidal behavior.

In April of 2004, a man in California was acquitted of attempted murder when it was found that his reaction to Zoloft made him unaccountable for his actions.

Zoloft is the most widely prescribed anti-depressant in the United Dates. Following some tests in 2004, the FDA put a "black box" warning on the drug, the strongest warning label that can be given to a drug, because of its association with an increased risk for suicide in children.

Yes, every now and then I stray from injury law, sometimes into other areas of law, sometimes further.

Associated Press writer, Janet Frankston Lorin, reports that David Chase, the well-known creator of the Sopranos (and other fine entertainment) is in the midst of a lawsuit.

At issue is whether the services Robert Baer provided during Chase's development of "The Sopranos" pilot should be compensated, and if so, their value.

Baer, also an aspiring screenwriter and former prosecutor, arranged meetings with experts during a three-day tour of New Jersey mob sites in 1995.

Baer testified that he declined Chase's offer of payment several times but said Chase agreed to "take care of him" if the show became a hit.

In court documents, Chase has called Baer "self-delusional."

Baer may or may not be self-delusional. One thing he definitely is, however, is careless. A careful person, especially an attorney, would have gotten a contract, not some vague representation that he would be "taken care of" if a show became a hit.

We'll stay tuned.

Driving in Reno is not (nearly) as bad as driving in Southern California or New York City, but we still have our share of accidents.

A UNR civil engineer professor and some UNR students are now researching roads and intersections in the Reno area to make them safer and less accident prone. The project entails videotaping certain intersections and studying tire marks or warning signs in "fender bender" areas.

The students have also set up surveys online and at the Department of Motor Vehicles that ask the public to identify high accident areas. Once these areas are located, the students review statistical data with an aim toward alleviating the problem particular to the spot. Read more about this project in the Reno Gazette.

Here is a list of ten questions from MSN, commented on by John S. Ford, MD, MPH in his California Medicine Man blog dated December 13, 2007

1) Do I really need this test? Great question but the author is preaching not to the choir, but to the tree stump. It's pretty well documented that as far as the patient is concerned: "Nothing is too good for my health...as long as someone else is footing the bill." My feeling is that it's the patient that is the main driver to more extensive test-ordering. This is really a question the doctor should be asking until such time as patients are required to assume a greater personal responsibility for their routine medical expenses.

2) Where would you send your wife or children? Another great question. In fact, this is a version of a question I try to ask myself and that I try to teach housestaff to ask on their patients' behalf: "What would I do if this patient was my mother-father-child-etc.? Nothing focuses the mind like putting yourself in your patient's place.

3) How many surgeries do you perform each year? I would rephrase this as "How many of this type of operation do you perform each year?" As the article notes, There's an substantial body of literature that supports the notion that practice does indeed make perfect. This is true for both surgeons and for the hospitals in which they operate.

4) Can I schedule my surgery in the morning? I wasn't aware that outcomes for first procedures of the day were better but it seems plausible. The surgeons I know are mostly morning people. I'm ashamed to say that when I was a medical student, I definitely saw surgical cases rushed through because they were the last ones of the day.

5) If I get sick, will you see me in the hospital? Uh oh. And the author was doing so well. The fact of the matter is that hospital medicine has become so specialized that its best practitioners are those that do it the most. In fact, I point out (with some irony) his suggestion of the ideal response to question 3. In fact there's a large body of evidence to support the notion that hospitalists have better outcomes, shorter lengths of stay, and more cost-effective care than non-hospitalists. If a GP isn't admitting large numbers of patients per year, his skills are going to get a bit atrophied.

6) Do you earn bonuses based on performance? This is a tough one. The premise of this question is that, "Many hospitals pay their physicians bonuses based on how quickly they move patients out the door." First of all, there are very few settings where hospitals pay bonuses directly to hospitalists. That said, there are many situations in which hospitalist performance is evaluated at least in part on patients' average length of stay (ALOS). I don't know that many hospitalist groups are so crass as to pay a straight bonus on this basis but it can pretty much be guaranteed that ALOS is definitely looked at in reviewing their salaries. However, other quality measures are definitely examined as well: outcomes, bounce-backs, patient satisfaction, etc.

Should you refuse care from any physician whose income is in some way affected by the ALOS? If so, you may find yourself being cared for by the guy delivering the meal trays.

7) When did you graduate from medical school? The author cites a review suggesting that doctors more than 20 years out of medical school are 48% less likely to be on top of current developments in their fields. Like everything in medicine, the key question is whether your doctor is representative of the population studied. If you have confidence in your doctor, he explains things well in an easy-to-understand manner, and has a personality that clicks with your own; I wouldn't put too much weight on this finding.

Of course as one who will shortly approach that 20 year mark myself, this piece of commentary may appear curiously self-serving.

8) What the hell does that say? The point here is that "neatness counts" when penmanship is the issue. There have been countless cases of serious badness (as my infinitely more hip residents like to say) due to poorly written prescriptions and hospital orders. Reviewing your prescription with your doctor and making sure it's legible is obviously a good idea.

9) Will you remove that wedding ring? Hmm. The idea is that the risk of transmitting an infection to the patient is greater if his care providers are wearing rings. I don't know if this has ever been formally studied.

I pubmed'd "wedding ring" and found papers in the field of dermatology (eczema, allergic reactions to metals), emergency medicine and orthopedics (how to remove stuck rings, ring-associated injuries), and urology (don't even ask).

I also found a rather intriguing article in the journal Nature entitled Earth Science: The Extraterrestrial Wedding Ring. I'll definitely have to check out that one out.

The point is that I don't know if the evidence supports asking your nurse or doctor to remove his wedding ring. The study cited by the author didn't examine infection rates, only bacteria counts which in this setting may or may not have clinical relevance. Personally, I'd feel a little funny asking someone taking care of me to remove their wedding ring, particularly a woman. Who knows what she'd think!

10) What else can I do to treat my condition? It's true that physicians often lag in their familiarity with medical interventions if they don't involve man-made chemicals or sharp instruments. In fact there are studies that demonstrate the benefits of diet, nutrition, and exercise. Unfortunately, the data supporting them may not be as dramatic or as robust as you might hope. However, I've encountered many physicians who market their practices by emphasizing these more natural treatments.

I have no problem with that at all. Just make sure your doctor also knows about man-made chemicals and procedures involving sharp instruments.

Alright, perhaps "plague" is too strong a word...

Last week the Washoe County District Health Department issued a boil water order for Cabela's and Boomtown Hotel and Casino. This was due to total coliform bacteria found in their water supply. According to the Environmental Protection Agency, total coliform bacteria are "natural and common inhabitants of soil and ambient waters (such as lakes and rivers) and are generally harmless. They are usually not found in ground water that is free of surface water or fecal contaminants."

Fortunately none of the 80 people evacuated from the hotel suffered side effects from exposure to the bacteria, symptoms of which include diarrhea, cramps, nausea, possibly jaundice, fatigue and headaches.

Last week the hotels worked to eliminate the bacteria in their water supply, but in the meantime Boomtown hotel wasshut down while the casino remained open. The Hotel appears to have now reopened.

According to the casino's general manager David Williams, "all the water systems have been disinfected including ice, soft drink and coffee machines, and chlorine has been added to the storage tank." He also stated that "we literally have a guy climbing up there [in order to add chlorine to the tank]."

What was the cause of this breakout? The hotel has had a clean bill of health according to Health Department records dating back to 1997, but a new water pump was recently installed. This pump is used to pump water from five wells into a 500,000-gallon storage tank for Boomtown, but it was evidently faulty and allowed bacteria to filter through with the water supply.

The Health Department does require the Boomtown public water system to take a sample for total coliform within its distribution system monthly, which is why this outbreak was caught. Fortunately, because nobody came down with any immediate symptoms this wasn't declared a medical emergency. It's also possible that people did come down with symptoms which they attributed to seasonal allergies, colds or the flu.

Obesity makes it harder for some people to fight infections and heal wounds, according to a Yahoo! News Article dated December 12, 2007. This may be due to the tendency of obese people to have weakened immune responses.

In a Boston University Research study, researchers tied silk threads laced with gum disease to the teeth of obese mice and mice of regular weight to compare the animals' response to the infection. It was discovered that the obese mice were more susceptible to the disease and were less able to fight the gum infection.

The white blood cells of the obese mice, which are mainly responsible for fighting infections, had lower levels of a signaling molecule and altered genes that fight inflammation. The study was not conclusive on why this connection exists. One theory is that constant exposure to food alters a signaling pathway that controls a protein, NF-kB, which, in turn, alters the ability of a person to fight infection.

The study also concludes that this process works the same in humans. In general, obese people are more likely to have gum disease as a result of a lower immune response to fight the infection and stop the inflammation properly.

The researchers also propose that new treatments should be developed for obese people that specifically target a weakened immune response system.

Reno is still pretty dangerous and challenging for bicyclists. This is largely due to the need for a better route of paths, better marked paths and a need for a better continuation of the paths network. Does this mean that Reno is an unsafe place for bicyclists to ride overall? Not necessarily, but there are certain precautions that every bicyclist should take, aside from simply wearing helmets while riding.

According to Reno Personal Injury Blog Staff Writer, George Goodwin, being aware and giving signs to let the drivers know that you are there is a first big step. Being alert, careful and polite also helps the bicyclist avoid potential problems. Some drivers are really good and some are great about riding in the middle of their driving lane, but that is not the case with all Reno-area drivers. You may also find that crossing at an intersection is safer than trying to cross while on the road because it gives drivers a greater area of clearance to drive by. It's better in any case to be safe than sorry.

As far as safety precautions you should take while on your bike, having two lights, a front and a rear, is a good start. Anything you can do to make yourself more visible, especially at night and in the cold winter months, is a positive step toward not getting hit.

In addition, keeping your bike tuned up and in decent condition will serve you well and help you to avoid potential traffic accidents. Keeping the air in your tires full and taking your bike to a bicycle shop to get the chains oiled and keep the tires trued (in a straight line) will help you to keep your balance and allow you to shift your gears smoothly whenever you meet a hill. While you're there you can have the mechanics check out any other problems that they might find such as frayed wires, bent spokes and misaligned handlebars. Any one of these might be a minor headache, but could potentially erupt into a major problem if left unchecked.

Drivers who take the whole lane are just as irresponsible as bicyclists who ride in wavy patterns, seemingly drunk. Generally, it's difficult to always place the blame on one specific group, but in a specific sense it's usually the fault of one or the other of the two involved. To avoid accidents bicyclists need to make drivers more aware that they are there and be more attentive as well. Drivers should also be more attentive and if they can't move over they should slow down. In addition, drivers should recognize that bicyclists are vehicles in their own right and instead of attempting to force bicyclists to move out of their (the drivers') way, they should recognize that bicyclists riding responsibly in their own lane are the equivalent to a moving vehicle themselves such as the car the drivers are currently driving.

According to the Nevada Department of Motor Vehicles Nevada bicyclists should "obey the law, wear a helmet, wear brightly colored clothing and keep bikes in good repair." Additionally, bicycles ridden at night "must have: a white lamp in the front visible from at least 500 feet away, a red tail reflector visible in a vehicle's low beams from 300 feet away and reflective material on the sides of the bike visible in low beams from at least 600 feet away or a lamp visible from both sides from 500 feet away."

These basic precautions on the part of the bicyclist will help to ensure their safety by making them more visible to drivers. However, not all bicyclists follow these precautions. In order to help fight this negative trend, the Nevada Department of Public Safety has begun a program called the "Nevada Bicycle and Pedestrian Safety Education Program" whose mission is "is to prevent injuries to children and adults from bicycle and pedestrian crashes by training them with the knowledge and skills needed to be competent and safe in traffic." Their goal of administering traffic and bicycle safety programs through workshops and education programs will hopefully have a positive impact throughout not only Reno and Washoe County, but all of Nevada as well.

The NDPS's stated safety goals include increasing proper bicycle helmet use, increasing obedience to traffic laws by pedestrians, bicyclists or motorists, increasing walking or bicycle use as a substitute commute to school or work increasing physical activity and reducing negative environmental effects thereby promoting a healthier community, and increasing and packaging educational opportunities in such a way as to encourage [their] widespread application. How do they reach these goals? The Office of Traffic Safety (OTS) provides ongoing education and funding opportunities, as well as special events targeting safety. Their targets run the gamut of elementary school students on up to adults, in an attempt to educate all levels of bicyclists to greater levels of safety.

What does all of this mean for a bicyclist? Those bicyclists who are careful, aware and visible are doing the right thing. By keeping their bicycles tuned up and making themselves visible not only during the daytime, but also at night, they are presenting themselves to drivers and making a statement of "I am here. Please be aware of me and take the proper safety precautions." Hopefully with enough education, the proper use of safety equipment and the use of safety precautions Washoe County will become less of a "challenge" for bicyclists and become more of a bicycling haven.

The name Aqua-Dots sends chills down the spine of families in the U.S. If you haven't heard about the recall that happened last month, then you are likely in the minority. About 4 million units of the product were recalled last month because they break down into a date-rape drug when ingested.

Currently 10 retailers and companies including Kmart, Walmart, Sears, Target and Mattel are being sued for their negligence in distributing Aquadots. Although they did put a disclaimer on the boxes that the dots are not for young children, it's impossible to police every child every second of every day. It only takes a second for a two-year old to grab a toy on a table and put it in his or her mouth, whether that toy was their elder sibling's or not. Four Australian children and two American children fell unconscious after ingesting the Aquadots, injuries which should not have happened in the first place.

Chinese companies are using increasing amounts of lead in their products to help increase the speed and volume of the toys that they are sending to the US and other countries. According to Macon.com, "lead poisoning - [is] the subject of about one-third of this year's recalls... from Oct. 1, 2006, through Sept. 31, 2007." All told there were about 25.6 million toys recalled this year, though the profiles of recalled toys were much higher this year than in previous years. Some parents are even going so far as to purchase lead testing kits to test on their children's toys or banning the purchase of Chinese made toys for their families all together.

It is true that products coming to the US must meet US standards, but regulating those products is sometimes sketchy. "It's not a new problem, but it's getting worse," said Ed Mierzwinski, consumer program director for the U.S. Public Interest Research Group, which released its annual report 'Trouble in Toyland'. "The reason it's getting worse is that manufacturers have stretched their supply chain to China, and the safety links are broken. Companies are not trying to pay attention to the law because they are not afraid of the CPSC [Consumer Product Safety Commission]."

So all things considered, it would probably be best to be careful of this year's toys and especially careful of most things made in China, not just toys. It's difficult to blame the Chinese for our own woes and even though toy manufacturers are going to put a foul-tasting chemical in Aquadots to prevent children from swallowing them, the fact that they need to in the first place makes a clear point: let the consumer beware.

According to a Reno Gazette Journal Article dated November 30, 2007, the new Reno triage center may have its budget cut after Governor Jim Gibbons ordered state agencies to submit lists for an 8% budget cut this month. This cut was an increase from an original 5% cut due to declining sales and gaming tax revenues.

The triage center is a center to help homeless people with mental health or substance abuse problems receive proper treatment and care. People can go through emergency detoxification or be transferred to another specialized facility for help. The idea is to put less strain on jails, hospital emergency rooms, and courts by dealing with these patients in a more personal manner.

The patients can stay up to 72 hours for psychiatric treatment, detoxification and non-acute urgent care. The facility will also have a women's and children's center, a soup kitchen, and a variety of other resources.

According to a February 14, 2005 Reno Gazette Journal Article, this center was originally created in response to a mental health emergency in Las Vegas. The legislation providing funding for a triage center in Las Vegas and also appropriated some funds to have a center set up in Reno to curb a similar health emergency.

Bristlecone Family Resources will be the facility that runs center at a cost of $1.8 million a year. This cost is to be split up between the state, local government, and private institutions.

The city of Reno has already spent $1.3 million dollars and five years on this project to date and the facility was set to open on January 1, 2008.

No decisions have been made by the governor to confirm whether the budget will definitely be cut for the center.

Thousands of patients are facing delays in crucial medical tests because of a shortage of a radioactive substance used in those examinations -- all because of the shutdown of one nuclear reactor in Canada.

According to Associated Press writers Charmaine Noronha and Stephanie Nano, the substance is used in at least 15 million medical scans a year in the United States, by one estimate. Those scans are used to diagnose and assess a wide variety of conditions including cancer, heart disease and bone or kidney illnesses.

They are often crucial for guiding therapy, telling a doctor whether a woman's breast cancer has invaded her bones, for example.

But over the past few days, many hospitals began facing a shortage of a radioactive substance called technetium-99 that is injected into patients to do these body scans. And that has forced them to cut back on the procedures.

"Many, many hospitals are working at about 20 to 30 percent of capacity" in doing the scans in the United States and Canada, estimated Dr. Sandy McEwan, president of the Society of Nuclear Medicine, based in Reston, Va. He said he didn't know how many scans had been postponed.

The shortage seemed to be hitting parts of Canada hardest. Dr. Chris O'Brien, president of the Ontario Association of Nuclear Medicine, put it this way to Canadian Press: "Last week, I guess you could describe it as struggling. This week it's devastating, and next week potentially catastrophic."

Ontario, for example, is now down to about half of its normal scan capacity, meaning about 1,000 patients a day are having their tests put off, he said.

"We don't know where to put these people," O'Brien said.

The Canadian Society of Nuclear Medicine estimates the shortage will cause delays in treatment for 50,000 Canadians each month that services are reduced.

While doctors can often turn to other tests, these can be more complicated and more awkward to interpret, experts said.

What's the cause of all this?

It's the unexpectedly long shutdown of a nuclear reactor in Chalk River, Ontario. The 50-year-old reactor is North America's biggest source of the radioactive isotope that makes technetium.

The owner of the reactor, Atomic Energy of Canada Ltd., shut it down Nov. 18 for what was supposed to be five days of routine maintenance. However, the company decided to keep it closed to do more work. The reactor will probably be working again by the end of December and almost surely by the end of January, the company says.

But in the meantime, the shutdown stopped the reactor's output of a radioactive substance called molybdenum-99, which is processed and packaged into canisters that are sold to big hospitals and specialized pharmacies. These cylinders are "milked" for their technetium-99, which is then prepared for use in the medical scans.

Since the technetium supply from each cylinder eventually peters out, the cylinders have to be regularly replaced. That's when the effect of the Chalk River reactor shutdown shows up.

Companies that make these cylinders say they're working with other molybdenum suppliers in Europe and South Africa to try to ease the shortage.

But in the meantime, the shortage has affected places like Caritas Holy Family Hospital in Methuen, Mass. Spokeswoman Danielle Perry said the 270-bed hospital has had to delay a few tests because of the shortage.
"We've already started to preserve our supply. We're giving priority to those patients with more urgent or critical needs," she said.

Larger hospitals are watching their supplies closely.

"We are going day by day," said Gopal Saha, director of nuclear chemistry and pharmacy at the Cleveland Clinic, which gets two canisters a week. No scans have been canceled there yet, he said Friday morning.

"I can't tell you what's going to happen tomorrow. It's clearly not a good situation," said Dr. Philip Alderson of New York-Presbyterian Hospital.

"I'm a little nervous. I'm concerned about where this is headed if this doesn't get resolved relatively quickly."
Alderson said his department learned Thursday that it would no longer get two molybdenum canisters a week, but instead will have to buy technetium dose-by-dose. That could pose a logistical problem if a patient suddenly needs a scan, he said.

"I'm worried about ... the patient who comes to the emergency room at 3 o'clock this afternoon with chest pain" and needs a lung scan to look for a clot, he said. "Will we be able to get that dose?"

McEwan said the nuclear medicine society has long pushed for the United States to build its own reactor to produce medical materials. That hasn't happened for a variety of reasons, including cost, he said. He called that "shortsighted."

The society is now working with federal regulators to expand the possibilities for using alternative tests, he said, and hospitals are sharing technetium-99 the best they can.

And what should patients think of all this?

"They need to talk to their doctors about the best alternative tests," McEwan said. And "they need to be assured that the whole industry is looking at alternative supply so they can resolve the issue as quickly as possible."

As Nevada's population of those with mental heatlh problems grows, the state has determined that it cannot spend as much as it did previously.

According to a Reno Gazette Journal Article dated November 30, 2007, the new Reno triage center may have its budget cut after Governor Jim Gibbons ordered state agencies to submit lists for an 8% budget cut this month. This cut was an increase from an original 5% cut due to declining sales and gaming tax revenues.

The triage center is a center to help homeless people with mental health or substance abuse problems receive proper treatment and care. According to a Reno Gazette Journal Article date January 18, 2005, at the center, people can go through emergency detoxification or be transferred to another specialized facility for help. The idea is to put less strain on jails, hospital emergency rooms, and courts by dealing with these patients in a more personal manner.

The patients can stay up to 72 hours for psychiatric treatment, detoxification and non-acute urgent care. The facility will also have a women's and children's center, a soup kitchen, and a variety of other resources.

According to a February 14, 2005 Reno Gazette Journal Article, this center was originally being created on the tail of a mental health emergency in the hospitals in Las Vegas. The legislation providing funding for a triage center in Las Vegas and also appropriated some funds to have a center set up in Reno to curb a similar health emergency.

Bristlecone Family Resources will be the facility that runs center at a cost of $1.8 million a year. This cost is to be split up between the state, local government, and private institutions.

The city of Reno has already spent $1.3 million dollars and five years on this project to date and the facility was set to open on January 1, 2008.

No decisions have been made by the governor to confirm whether the budget will definitely be cut for the center.

General Electric recalled 92,000 combination wall and microwave ovens after at least 35 incidents of fire that damaged property, the company and the Consumer Product Safety Commission said Wednesday.

According to a Yahoo News article yesterday, the door switch in the microwave oven can overheat and ignite plastic components in the appliance, the company said.

The lower thermal oven does not pose a hazard and no injuries have been reported, according to the commission.

Department and appliance stores sold the ovens between January 2000 to December 2003.

A startling 11% of those in a 200,000-patient national sample did not receive a lymph node assessment while undergoing surgery for early-stage breast cancer. The recommended practice promotes disease staging and appropriate treatment selection.

Garth Sullivan, Esq., at Indox Consulting (415-568-7116) reports that researchers explored the impact of patient race and ethnicity, insurance status, and age on their receipt of axillary lymph node assessment. They controlled for other sociodemographic and clinical factors using multivariate logistic regression.

The group found that women without insurance were 24% less likely to receive a lymph node assessment than those with private insurance. Women who lived in areas with low levels of education were 13% less likely to have the procedure than those in areas reporting high levels of education. And black patients were 10% less likely to have the procedure than white patients.

"We were really surprised by the number of nonclinical factors associated with patients not receiving an assessment," Dr. Halpern told Medscape Oncology.

The group also found that age was a major factor in determining who received a lymph node assessment. The researchers reported that women 73 years or older were 3 times less likely to receive the procedure than were patients 51 years or younger.

But Dr. Halpern said he was less concerned by this finding, considering practice guidelines for axillary node dissection during lumpectomy or mastectomy surgery suggest the procedure is optional for elderly patients, for those with other serious illnesses, and for patients in whom lymph node results wouldn't affect choice of therapy.

Dr. Halpern pointed to a number of limitations to the study, including its reliance on a database. "Roughly 25% of cancer patients would not be included in the national data and would be at other hospitals, so we clearly do not have everyone here," he said. "We also don't know why the patients' lymph nodes were not assessed. Was this a patient-driven phenomenon? Or was this coming from the surgeons? We don't know what factors were influencing the decisions," he added.

Other studies have suggested that disparities in care result from different sources, including structural barriers such as health insurance; type of hospital, physician, or clinical factors; and patient factors.

"All of these may be important in the disparities we observed for axillary node dissection," Dr. Halpern said. "We need to find out why these disparities exist and what to do to make sure that everyone is receiving excellent cancer care."

Tests on more than 1,200 children's products, most of them still on store shelves, found that 35 percent contain lead -- many with levels far above the federal recall standard used for lead paint.

According to an AP article released today, a Hannah Montana card game case, a Go Diego Go! backpack and Circo brand shoes were among the items with excessive lead levels in the tests performed by a coalition of environmental health groups across the country.

For your very own toxic toy guide to to: http://www.healthytoys.org

Relax: your cell phone might not be a bomb after all.

A South Korean man whose death initially was blamed on an exploding cell phone battery was killed by a car accident involving his colleague, police said Friday.

The International Herald Tribune reports (November 29th) that the quarry worker, only identified by his family name Seo, was found dead Wednesday with a melted phone battery in his shirt pocket. Police and a local doctor who examined his body said the battery may have killed the man.

The colleague, identified only by his surname Kwon, confessed to police that he accidentally killed Seo while he was backing up a drilling vehicle but first reported to police that the death was caused by the battery explosion, Min said.

That's quite an alibi...

Eight men say they either had sex with Sen. Larry Craig or were targets of sexual advances by the Idaho lawmaker at various times during his political career, according to Yahoo News citing the Idaho Statesman newspaper.

Amid pressure from top GOP leaders in Washington, Craig announced his intent to resign from the Senate. He later changed his mind, deciding to finish out his term, which expires in January 2009. He is also appealing in Minnesota courts to have his guilty plea overturned.

The newspaper identified four men and reported details of the encounters they say involved Craig. It also reported the accounts of four other men who did not agree to be identified but who described sexual advances or encounters involving the conservative Republican, who opposes same-sex marriage and has a strong record against gay rights.

One wonders if the Idaho Statesman would have been so intent on attempting to further expose Craig if Craig had not been so intent on denial...

In American, politics and injury law are sometimes hard to separate, and attorneys are often misidentified as liberal or conservative depending on their view of whether an injured party deserves compensation. At the end of the day, we're all Americans though (and let's face it: those who support adequate compensation for victims are better Americans)...

I have a background in international law, I follow international news, and every now and then I'll "cross borders," so to speak, to comment on some international event that transcends injury law.

On this note, I'm happy to re-report that one of the world's great nutcases, Hugo Chavez, narrowly lost his electoral bid to "stand indefinitely" for re-election and thus move Venezuela toward what has characterized many socialist states: a crazy dude in power who just won't go away. Or, more plainly put: a dictatorship.

The world's a better place without an indefinite Chavez and it's nice that a majority Venezuelans have determined to act in thier own sane interest. Perhaps one day the only audience in front of which Chavez will rant will be himself.

In Nevada, as elsewhere, one has to look out of state to find a medical expert witness to testify. Nevada doctors do not testify against each other. Similarly, I suspect that a review of State Board of Medical Examiners complaints would reveal that the vast majority of such complaints come from patients.

It comes as little surprise, therefore, that nearly half of all U.S. doctors fail to report incompetent or unethical colleagues, even though they agree that such mistakes should be reported, researchers said on Monday.

Reuters reports that Eric Campbell, a professor at Harvard Medical School, recently released survey results in which researchers found that 46 percent of physicians surveyed admitted they knew of a serious medical error that had been made but did not tell authorities about it.

"There is a measurable disconnect between what physicians say they think is the right thing to do and what they actually do," said Eric Campbell of Massachusetts General Hospital and Harvard Medical School in Boston, who led the survey.

Doctors are also surprisingly willing to order unnecessary -- and often expensive -- tests such as magnetic resonance imaging or MRI scans. Just 25 percent said they were looking out to ensure they did not unintentionally treat someone differently because of their sex or race, the survey found.

In 2000, the U.S. Institute of Medicine reported that up to 98,000 people die every year because of medical errors in hospitals alone.

Campbell and colleagues surveyed more than 1,600 physicians in 2003 and 2004 for their report, published in the Annals of Internal Medicine.

Up to 96 percent of those surveyed said they should report all instances of significant incompetence or medical errors to the hospital clinic or to authorities. The exception was among cardiologists and surgeons, with just about 45 percent agreeing.

And 85 percent of most doctors said they should tell patients or relatives about significant errors.

But this did not translate into practice.

Forty percent of the doctors said they knew of a serious medical error in their hospital group or practice but 31 percent admitted they had done nothing about it at least once.

Doctors also did not always practice what they preached ethically. While 93 percent of doctors said they should provide care regardless of a patient's ability to pay, only 69 percent actually accepted uninsured patients who cannot pay.

LETTING COMPETENCE SLIDE

While most of the doctors agreed they needed to keep up with changes in the profession and have their competence reviewed, only 31 percent had undergone a competency review in the past three years.

Dr. James Thompson, chief executive officer of the Federation of State Medical Boards, said one problem may be that doctors know there is not much that can be done to help doctors who are struggling to be competent.

"There are very few places where they can send them for remediation," Thompson told a news conference.

And medical boards may not have the resources to punish errant doctors.

"There are restrictions on state medical boards that inhibit their ability to go after physicians aggressively," Thompson said.

"There are state medical boards that don't even have their own teams of investigators," he added. "There are state medical boards that are, quite frankly, underfunded and understaffed."

But he said medical boards cannot act unless someone reports a problem doctor.

"State medical boards only react to complaints -- they are not a policing agency," Thompson said.

In Martinez v. Maruszczak, 123 Nev. Adv. Op. No. 43 (October 11, 2007), the Nevada Supreme Court considered " the extent to which sovereign immunity protects publicly employed physicians from common-law liability for medical malpractice."

The Court's analysis turned "on Nevada's statutory waiver of sovereign immunity and a statutory exception to that waiver, which immunizes state actors from liability for actions grounded upon the state actor's exercise or performance of a discretionary function or duty. Because Nevada jurisprudence concerning the scope of the discretionary-function exception is unclear, and because Nevada's statutory language mirrors the Federal Tort Claims Act," the Court adopted a two-part federal test for determining when the discretionary-function exception to the general waiver of governmental immunity applies.

"Under this two-part test, state-employed physicians enjoy immunity from medical malpractice liability only when their allegedly negligent acts involve elements of judgment or choice, and the judgment or choice made is of the kind that the discretionary-function exception was designed to shield, that is, a judgment or choice involving social, economic, or political policy considerations.

If those two requisites for discretionary-function immunity are not satisfied, state-employed medical professionals are liable for malpractice to the extent of the statutory cap that applies to damages awards in tort actions against state employees."