Category: MRSA

Butch Cassidy’s Question

Butch to Sundance: "Who are those guys?"

Butch to Sundance: “Who are those guys?”

In the 1969 Western classic Butch Cassidy and the Sundance Kid, our two outlaws and their Hole in the Wall Gang rob a Union Pacific train on both its eastward and westward runs, thinking that the second robbery would be unexpected and likely reap even more money than the first.

Problem was, the second robbery wasn’t so unexpected: Union Pacific, tired of being robbed, hired a six man Superposse to follow the train. It included renowned Indian tracker Lord Baltimore and relentless lawman Joe Lefors, who tore after Butch and Sundance in hot pursuit, night and day, without pause, “like a machine.” After using every trick in the book to elude the Superposse, and failing to do so, an exhausted Butch peers out from behind mountain rocks at the advancing trackers below and says to Sundance, “Who are those guys?”, a refrain repeated throughout the chase.

Misjudging an opponent is something the medical community is currently reckoning with when it comes to microbes and their increasing resistance to the antibiotics we use on them. Exactly, Who are those guys? — i.e. microbes — is a central question addressed by Brad Spellberg, MD, Chief Medical Officer at the Los Angeles County-University of Southern California Medical Center, in his book Rising Plague: The global threat from deadly bacteria and our dwindling arsenal to fight them. Like Butch & Sundance’s Superposse, Spellberg and other leaders in the field of infectious disease have learned that bacteria and Superbacteria are not what we thought they were either. In essence, we underestimate them, too.

For example, Spellberg points out in his book that:

1. Microbes have existed for a thousand times longer than our species, outnumber us by a factor of 1022, outweigh us by a factor of 108, and represent 60 percent of the mass of life on the planet.

2. They reproduce “almost impossibly quickly.” E. coli bacterium, for instance, can create 69 billion progeny in just twelve hours of growth. “Now that’s an enemy for you,” says Spellberg. “Kill one and as many as 69 billion more can pop up within twelve hours.”

3. About 1.5 million of the 69 billion offspring can have mutations that enhance their ability to survive in hostile environments, such as the presence of antibiotics that would otherwise be lethal to the bacteria.

4. This “astounding replication and mutation rate,” i.e. the evolution in bacteria of resistance to antibiotics, is the method by which bacteria create new weapons and defense mechanisms within generations.

Here’s the neat part: the video below, developed at Harvard Medical School, allows us to watch the evolution of Superbacteria in action. It shows billions of bacteria breaking through ever stronger barriers of antibiotics inside a really big petri dish, or mega-plate. As the bacteria move towards the middle of the plate from both ends they are eating, growing, and multiplying. Along the way, they’re also mutating and evolving. As the bacteria move inwards, mutants evolve that are resistant to increasing doses of antibiotics that would otherwise — but for the mutations — kill the bugs.

Crucially, the evolution of bugs on the mega-plate mirrors real life, says Harvard’s Roy Kishony in an interview with STAT: “Every single antibiotic that we have introduced medically so far, the bacteria found ways to evade it … every single one.”

In other words, just like the Superposse chasing Butch & Sundance, nothing – no amount or kind of antibiotic – can stop the advance of the Superbacteria either.

Check it out:

In Praise of Vaccines: They also help fight the spread of antibiotic resistance



We knew vaccines were good stuff. For example, according to a 2014 editorial in Science, “Vaccines are one of the safest and most cost-effective medical interventions in history. By immunizing infants, children, and teenagers, vaccines protect the entire community.”

And then just a few weeks ago we learned of yet another benefit. According to the World Health Organization vaccines can help fight the spread of antibiotic resistance, which the United Nations just called “the greatest and most urgent global risk.”

For example, as we enter the height of cold and flu season — December through March — the WHO says that vaccines not only protect us from those ills, they can also confer an added health benefit: “Vaccines against viruses, such as the flu, also have a role to play, because people often take antibiotics unnecessarily when they have symptoms such as fever that can be caused by a virus.”

The unnecessary use of antibiotics – i.e. overuse (e.g. in our food animals) and misuse (e.g. they don’t work on colds) – drives the resistance problem. Therefore, according to the WHO, “Vaccinating humans and animals is a very effective way to stop them from getting infected and thereby preventing the need for antibiotics.”

We tend to overlook the massive dosing of our food animals with antibiotics. One reason we give healthy animals antibiotics is to prevent them from getting sick — but you should no more give a healthy animal an antibiotic than you should a healthy person. As we noted this past April, the problem is vast:

“Over 8 tons of antibiotics are fed every year to the more than 8 billion food animals in the US alone, resulting in a ‘massive selection’ for resistant bacteria, writes Stuart Levy, MD, in his book The Antibiotic Paradox: How the misuse of antibiotics destroys their curative powers. With the upshot, Levy says, that resistant bacteria will develop in an animal within 2 – 3 days; from there it will spread to the other animals, then to the farm workers and their families, continuing outward to nearby communities, states, and even globally.”

Finally, the WHO also recommends expanding the use of existing vaccines in people. For example, they say that “if every child in the world received a vaccine to protect them from infection with Streptococcus pneumoniae bacteria (which can cause pneumonia, meningitis and middle ear infections), this would prevent an estimated 11 million days of antibiotic use each year.”

As we begin to tap in to this potential for vaccines — which includes the development of new ones — perhaps it will also help prevent one of the more dire scenarios that worries leading health authorities: that by the year 2050 antibiotic resistant disease will kill more people each  year than cancer.

Noam Chomsky Weighs in on Antibiotic Resistance: “We May Be Destroying Ourselves in That Way Too”

“Judged in terms of the power, range, novelty and influence of his thought, Noam Chomsky is arguably the most important intellectual alive today,” wrote the New York Times back in 1979. Since then, the polymath Professor Emeritus of Linguistics at MIT went on to prove the paper correct as he became the eighth most cited source in the history of the humanities: Marx was first, then Lenin, Shakespeare, Aristotle, the Bible, Plato, Freud, Chomsky, Hegel and Cicero. “What it means is that he is very widely read across disciplines and that his work is used by researchers across disciplines,” said the Humanities Librarian who checked the numbers.




Many of us have been waiting for him to weigh in on antibiotic resistance because, for example, a heads-of-state meeting of the United Nations last month called it “the greatest and most urgent global risk.” And finally, just this month, from his office at MIT, he addressed it in an interview whose theme can be summed up in this question and answer:

Interviewer: If we don’t fix our problems, will the 21st Century be the last century of humanity?

Chomsky: Probably not of humanity but of organized human life on Earth.

In other words, says Chomsky, the question we face is: “Are we going to survive?” which he calls “The most serious problem that has ever arisen in human history.”

Two main drivers of our existential crisis are the ones we would suspect: “environmental catastrophe” and “the threat of nuclear war today [which] is greater than it was during the Cold War,” he says.

But after he made his case on those counts came the following surprise:

“I mentioned two [problems] which are enormous but there’s more than that. Another major problem is the threat of pandemics — diseases that can’t be controlled. That’s already happening, and it’s happening for important reasons. One reason that we haven’t mentioned … is industrial meat production. Industrial meat production is a huge contributor to global warming. It’s an enormous producer of carbon dioxide and methane.”

Then focusing on the resistance issue, he continued:

But it also has another feature. Corporations pour antibiotics into these systems. Animals are crowded together in horrible conditions and to prevent disease and to maintain growth there’s an extensive use of antibiotics. An enormous part of antibiotic production is for this. Use of antibiotics leads to mutations which make bacteria antibiotic resistant. We’re now … the rate of antibiotic resistance is growing faster than the techniques for dealing with them. So we may be destroying ourselves in that way too.


There’s something else about these issues that concerns Chomsky, as well: “If you watch something like the current electoral campaign … [you’ll] notice a very curious fact: None of this is being discussed.” “What strange form of intelligence,” he asks, “is it that enables great accomplishment to be achieved but is unable to ask the question, will we survive and how can we ensure our survival?


The leading causes of death are heart disease and cancer — Right?

As the headline news across the U.S. tracks the death toll of Hurricane Matthew — 108, as of this writing — the headline that you won’t see today concerns the growing body of evidence suggesting that the leading cause of death in the country is neither heart disease nor cancer: It’s death due to infection.

That’s the conclusion reached by a 2014 University of Michigan study, “Death Certificates Underestimate Infections as Proximal Causes of Death in the U.S.” Don’t be misled by the conservative title because the researchers contend something extraordinary: that if the count was performed by looking at patients’ Medicare billing records, which show what they were being treated for, rather than death certificates, which they say are unreliable, you would end up with the following tally (‘Malignancy’ means cancer):




It’s the use of the different data set — Medicare insurance records — that gets you the significantly different result in column 3. Where infection not only comes out as the leading cause of death in the country, but does so by a full 11 percentage points over heart disease, which comes in second.

The Michigan study by no means stands alone in saying that death certificates are not a reliable indicator of what is actually killing us.

For example, U.S. Centers for Disease Control research published in 2010 found that in a survey of 521 New York City doctors: (1) 48.6% of them had knowingly reported an inaccurate cause of death on a death certificate, and (2) only 33% of them believed the current cause-of-death reporting system in New York City is accurate.

Recent eye-opening investigations by The Los Angeles Times and Reuters offer corroborating evidence.

The Reuters report, “The Uncounted: The deadly epidemic America is ignoring,” found that tens of thousands of “superbug” deaths in the U.S. are going uncounted because the death certificate omits any mention of the infection. Or because, even when it does, neither state health authorities nor the federal Centers for Disease Control bother to keep track of the numbers

The reasons for the huge undercount are indeed troubling. Reuters: “Counting deaths is tantamount to documenting your own failures. By acknowledging such infections, hospitals and medical professionals risk potentially costly legal liability, loss of insurance reimbursements and public-relations damage.” And so hospitals will even hide the true numbers of infections.

Here’s an excellent summary of their work:


Just a few days ago, the Los Angeles Times published “No one knows how many patients are dying from superbug infections in California hospitals.” In a conclusion mirroring that of Reuters, the Times found that because “California does not track deaths from hospital-acquired infections [and because] California does not require hospitals to report when patients are sickened by [some] superbug[s],” that, “an epidemic of hospital-acquired infections is going unreported.”

“Science begins with counting,” writes physician-researcher Sid Mukherjee MD, in his 2011 Pulitzer prize-winning book, “The Emperor of all Maladies: A Biography of Cancer.” “To understand a phenomenon,” says Mukherjee, “a scientist must first describe it; to describe it objectively, he must first measure it. If cancer medicine was to be transformed into a rigorous science, then cancer would need to be counted somehow—measured in some reliable, reproducible way.”

To borrow from Dr. Mukherjee, then: “If infectious disease medicine is to be transformed into a rigorous science, then infectious disease would need to be counted somehow—measured in some reliable, reproducible way.” This matters, because as the emerging evidence suggests, infections may well be the leading cause of death in the U.S., and by extension, throughout the world.

Off the Record: Only “A Tiny Fraction of the Actual Toll” of Superbug Deaths are being Reported, says Reuters

Tens of thousands of “superbug” deaths in the U.S. are going uncounted because the death certificate omits any mention of the infection. Or because, even when it does, neither state health authorities nor the federal Centers for Disease Control bother to keep track of the numbers, concludes an eye-opening investigative report from Reuters, “The Uncounted: The deadly epidemic America is ignoring.”

On the state level, the discrepancy between the number of superbug deaths reported and the true numbers is staggering. For example, state health records for the period 2003 – 2014 reveal 3,300 deaths caused by superbugs. But the Reuters analysis — working with the CDC’s National Center for Health Statistics’ Division of Vital Statistics to search text descriptions on death certificates to identify relevant deaths — found 180,000 such deaths. (The state-by-state comparison can be seen in the “Through the cracks” graphic, below.)


Kelly and Ryan Breaux lost their 4-year old daughter Emma, to MRSA. The death certificate blamed the flu.

Kelly and Ryan Breaux lost their 4-year old daughter Emma, to MRSA. The death certificate blamed the flu.


On the federal level, the CDC estimates that about 23,000 people die each year from 17 types of antibiotic-resistant infections and that an additional 15,000 die from Clostridium difficile, a pathogen linked to long-term antibiotic use. But even the CDC concede they don’t have the numbers right.

For example, Michael Craig, the CDC’s senior adviser for antibiotic resistance coordination and strategy, said the agency, pressured by Congress and the media to produce “the big number,” settled on “an impressionist painting rather than something that is much more technical.” Describing the estimates to Reuters, CDC officials used words like “jerry-rig,” “ballpark figure” and “a searchlight in the dark attempt.” Thus, say Reuters, you’re “introducing so much statistical uncertainty into the numbers as to render them useless for the purposes of fighting a persistent public health crisis.” And so “in the absence of a unified national surveillance system, the onus of monitoring drug-resistant infections and related deaths falls on the states” … where we have a documented discrepancy of 3,300 reported vs. 180,000 actual, deaths.

The reasons for the huge undercount aren’t pretty. For instance, according to Reuters, “counting deaths is tantamount to documenting your own failures. By acknowledging such infections, hospitals and medical professionals risk potentially costly legal liability, loss of insurance reimbursements and public-relations damage.” And so hospitals will even hide the true numbers of infections:


At a conference last year, hospital infection-control specialists told CDC officials that medical staff and internal review boards sometimes blocked them from reporting infections as required by state law or by the Centers for Medicare & Medicaid Services (CMS), which reduces payments to hospitals for preventable infections and high infection rates.

The specialists said medical staff sometimes were discouraged from testing patients with clear signs of infection – one of several tactics they said staff used to get around reporting rules.


Getting the numbers right matters because you need to know when, where, and how many deaths are occurring and who is most at risk. That determines where money and manpower — e.g., for basic research, drug development, and public health campaigns — are needed the most. The way to do it, say industry experts, is to copy the HIV/AIDS model.

Within three years of the first AIDS cases in 1981, most state health departments required hospitals and physicians to report and name each new diagnosis. Surveillance systems soon evolved to capture each AIDS-related death. Health officials used that information to direct resources to the hardest-hit areas and study how the disease was spreading. As a result, activism swelled, helping to attract millions of dollars for public education campaigns and drug development. The number of infections then peaked at about 78,000 in 1993 and rapidly fell thereafter. In 2013, the latest year for which numbers are available, about 13,000 people died with AIDS. So far, drug-resistant infections haven’t prompted anything like that sort of broad mobilization.

Until we adopt such a model we know that we will continue to have avoidable tragedy’s like that of 4-year old Emma Grace Breau. Reuters reports:


She contracted an infection shortly after her birth at the Lafayette General Medical Center in Lafayette, Louisiana, in 2005. Emma had a MRSA infection. She survived, but with permanent damage to her heart, lungs and one leg. Three and a half years later, Emma was in Florida to have her leg repaired when she came down with swine flu. It was too much for her heart and lungs. After a six-week battle, she died at Miami Children’s Hospital just shy of her fourth birthday. Her death certificate blamed flu-related pneumonia. Including MRSA as a cause of death ‘was not considered,’ said Dr Sharon Skaletzky, who was at Miami Children’s at the time and signed the death certificate … Her medical expenses alone eventually exceeded $4 million for repeated hospitalizations due to complications from her MRSA infection. The family sold their home, truck and other possessions to stay afloat while she underwent multiple operations.








Taylor’s Story

Taylor Church 3


On Tuesday, the US Centers for Disease Control declared sepsis to be a “medical emergency.” Also called septic shock, it occurs when the body creates an overwhelming response to an infection, and chemicals released into the bloodstream (because that’s where the infecting bug is) cause inflammation, tissue damage, organ failure, and oftentimes, death.

The CDC is drawing attention to this issue because 1 – 3 million Americans are diagnosed with sepsis each year, about 25% of whom die, and because — and this is the key — 80% of the cases occur outside of a hospital. And for that very reason people are dying needlessly because the symptoms of sepsis are usually misinterpreted as something familiar and benign: at bedtime we may be thinking the flu but by morning we have runaway sepsis — and no time to lose.

Taylor Church’s story illustrates the problem. Taylor was then a healthy twenty-one year old, the mother of an 18 month old boy, Aiden, and excited about starting nursing school the following week. She had been feeling a bit run down — it was probably just the flu — so she had stayed home for a few days. Suddenly, though, things went downhill. She went to the hospital and then, surprisingly, was whisked into surgery. She had no idea what she was facing. The following video is Taylor, soon after her surgery, telling you what happened (please watch):



When Taylor went into surgery she didn’t know she was facing amputation: “I didn’t know that they were taking my hands and feet. I woke up like this.”

Like most sepsis patients, Taylor was at home when it began and chalked it up to the flu. And by the time she sought medical care it was too late.

Taylor’s story is also unique. Anyone can contract sepsis but almost ¾ of sepsis patients are vulnerable to begin with. For example, they are over 65, and are living with some chronic conditions like diabetes and, especially, pneumonia, which is reported in 35% of sepsis cases.

The CDC tells us that the bugs usually associated with the initial infection are Staphylococcus, Escherichia coli (E. coli), and some types of Streptococcus. Interestingly, in 1/3 of patients no pathogen is ever identified. This suggests that the burden of disease cause caused by these pathogens is much greater than is being reported.

The CDC issued the medical emergency so we will “think sepsis” when we see one of the following six key signs of it:

Shivering, fever, or feeling very cold

Extreme pain or discomfort

Clammy or sweaty skin

Confusion or disorientation

Shortness of breath

A high heart rate

These are the warning signs, say the CDC, that you’re in the midst of a medical emergency, and therefore need to “act fast.”

Four years ago when these signs were little known, Taylor Church, understandably, thought she had the flu. And so now, post-amputation, Taylor says, “I’ll make the best of this. I will make the best of this.”

Taylor Church puts her story out there for one reason: she hopes that someday you won’t find yourself having to find the strength and courage to utter those very same words.

The Nursing Home, the Hospital, and the Elderly

Three pieces of evidence, examined together, suggest that it is our elderly who are most at risk for being harmed by the rising plague of infections resistant to treatment, i.e., antibiotic therapy—especially if they’re in a nursing home or a hospital.

Beginning with the nursing home, we recently reported that:

“Current data suggests that here are nearly 3 million infections in nursing homes every year, resulting in 150,000 hospital admissions and 300,000 deaths.  As the US nursing home population is expected to increase from 3 to 5 million by 2030, we can expect to see a larger burden of these types of infection.”

Those are the words of James A. McKinnell, MD, an Infectious Disease specialist from Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute. Using a more comprehensive method (the “Zorro swab“)to determine the prevalence of superbugs in nursing homes, his group found significantly more drug-resistant pathogens than previous studies have. For example, almost half of all nursing home residents are colonized with at least one superbug; nursing homes themselves are awash with superbugs as almost 90% of the rooms are contaminated with at least one of them; and methicillin-resistant staph aureus (MRSA) is the most prevalent bad bug, as it was found in almost two-thirds of the rooms.

Thus, says Dr. Mckinnell, “When a facility tells me their rates are 6%, I usually add 30% to account for all the missed and untested multidrug-resistant organisms.”

elderly 6

Second, when you think of nursing homes you also have to think of hospitals, because the elderly are constantly transferred between the two. And therefore, “a silent transmission [of pathogens] goes on” from the nursing home to the hospital.

But what about the hospital itself? Can you pick up bugs there and transmit them back to the nursing home?

A landmark study found that 1 in 12 adult patients in Canadian hospitals are either colonized or infected with a bug that’s resistant to drug therapy. Again, the major culprit was MRSA.

But there’s an inside story to the study that for some reason never gets mentioned: the average age of the people colonized or infected was 72 (See Table 3).

These people, of course, are the very ones most likely to require nursing home care after their release from hospital.

Finally, we are seeing “a tremendous shift” in elderly patients with infectious disease who require ICU care: In 1996 it was the 11th-ranked diagnosis for elderly in the ICU; today it’s the top-ranked diagnosis, replacing cardiovascular disease. That surprised the researchers because the elderly have such a high prevalence of coronary artery disease and congestive heart failure.

One conclusion Dr. Mckinnell drew from his study is that “Nursing homes are the perfect storm of [elderly] patients carrying pathogens and at the same time at [an increased] risk of getting sick if they are exposed to them.”

However, if we were to consider the other two studies alongside Dr. Mckinnell’s, we might rephrase his conclusion to this: “Nursing homes and hospitals together, are the perfect storm of [elderly] patients carrying pathogens and at the same time at [an increased] risk of getting sick if they are exposed to them.”



A new front opens up in germ warfare — the nursing home

Underneath the tranquil exterior of the nursing home lies a thriving community of new-found members whose presence poses an imminent threat to our elderly: i.e., multi-drug resistant organisms (MDROs) — aka “superbugs,” bad bugs, germs, or pathogens. Those invisible creatures that, in gangs of tens of millions or more, are in us, on us, and around us, and drive those nasty infections that antibiotics increasingly have no control over. So much so that:

“Current data suggests that here are nearly 3 million infections in nursing homes every year, resulting in 150,000 hospital admissions and 300,000 deaths.  As the US nursing home population is expected to increase from 3 to 5 million by 2030, we can expect to see a larger burden of these types of infection.”

The stunning quotation is from James A. McKinnell, MD, (email correspondence, 6/22), an Infectious Disease specialist at the Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute. He is also the co-lead author of an eye-opening new study that says there’s significantly more of these drug-resistant pathogens in our nursing homes than we knew. For example:

1) Almost half (47.5%) of the people in nursing homes are colonized with at least one superbug.

2) Nursing homes themselves are awash with superbugs: 88% of the rooms are contaminated with at least one. And watch out for the bedside table/bedrails as 86% of them are contaminated with at least one superbug.

3) The big dog is Methicillin-resistant staphylococcus aureus (MRSA). They were found in almost 2/3 of the rooms (65.2%); followed by VRE (46.4%), ESBL (26.4%), and CRE (5.1%).

4) We also know that these 4 bugs aren’t the only ones living in nursing homes. The Centers for Disease Control tells us there are 18 superbugs whose threat to our health is either “urgent” (such as CRE), “serious” (MRSA, ESBL, and CRE), or “concerning.” In other words, Mckinnell’s team, looking for less than ¼ of the known threats (a demanding task in itself) found almost 9 in 10 rooms colonized with these disease-causing drug-resistant pathogens.

5) Interestingly, the bugs in the room don’t always match the bugs on you. For example, among MRSA carriers, almost 2/3 of them (64.1%) had their rooms contaminated with non-MRSA bugs, thus exposing them to new and different superbug acquisition.

elderly 2

Dr. Mckinnell’s study matters because his group did something different: they looked harder. Investigators typically check for pathogens in just the nose — but why stop there? Using the so-called Zorro technique (the search mimics the motion the fictional character Zorro makes with his sword) his team checked the left armpit, right armpit, left groin, and right groin.

And voila, detection increased by 20%. In an interview with Medscape, Mckinnell reports that “We found 160 patients with MRSA. If we had only done nares, we would have only found 121; we would have missed 39 carriers.” Thus, he says, “When a facility tells me their rates are 6%, I usually add 30% to account for all the missed and untested multidrug-resistant organisms.”

The upshot is that “Nursing homes are the perfect storm of patients carrying pathogens and at the same time at [an increased] risk of getting sick if they are exposed to them.” The elderly have weaker immune systems, are more likely to have a history of MDRO carriage, be bed-bound, or be in need of a catheter, each one a risk factor for infection.

And the risk spreads. As others have pointed out, in the revolving door between the nursing home and the hospital, if colonized individuals are admitted to the hospital without having been screened, a silent transmission of pathogens can emanate throughout the healthcare system.

Estimates vary, but there seems to be at least twice as many people in nursing homes as there in hospitals in the US. The point of intervention, then, is clear: you want to debug — decolonize — people at the nursing home.

But there’s a trick to it. Targeted prevention becomes difficult when nearly half the patients in a nursing home are colonized with a MDRO, says Dr. McKinnell. Therefore, “We need universal interventions that protect everyone, and enhanced ones for those who need more protection.”

There’s one more consideration, captured in the dictum attached to Dr. Mckinnell’s emails, which reads: “Pick your travel partners wisely. You walk this road only once.” Sage words indeed; which assume, of course, that we have the ability to pick our partners in the first place — and thankfully, most of us do.

But not everyone. When you’re in a nursing home a great many of your partners are picked for you. We can’t see them, but we know they’re there — in the tens of millions — because they’re killing us. That’s not hyperbole. Look again at the number of nursing home infections, hospital admissions, and deaths, in the block quotation of Dr. Mckinnell, above. Now look at the three ladies in the picture and let’s ask ourselves a question: If we don’t engage in the universal interventions that Jamie Mckinnell is asking for, are we fulfilling our duty of care to the elderly?



Good medicine: It’s time for doctors and lawyers to work together to reduce the risk of medical error

Two months ago, physician Richard Horton, editor-in-chief of The Lancet, a United Kingdom-based medical journal, published a piece called “The rule of law: an invisible determinant of health.” In it, Horton says that “Public health advocates do not typically see the law as a critical influence on health. They are wrong.”

Horton’s Exhibit A in support of his thesis might well be its application to medical error.

Earlier this month a couple of physicians from the Johns Hopkins University School of Medicine in Baltimore, published a landmark analysis of medical care gone wrong, concluding: “If medical error was a disease it would rank as the third leading cause of death in the United States,” behind only heart disease and cancer.

Law & medicine, united, could be a formidable team

Law & medicine, united, could be a formidable team

Yet the astronomical 251 000 deaths a year they attribute to medical error “probably underestimates the scope of the problem,” say the authors, because (1) they used conservative numbers in their analysis (2) they counted hospital figures only, thus excluding doctor’s offices, ambulatory care centers, nursing homes, and so on (3) harm less than death was not counted, and (4) the problem is worldwide; Canada and the UK were specifically singled out as likely to be on par with the US.

There’s also a certain slight-of-hand going on with respect to medical error: it’s not just that over 250 000 such deaths aren’t being reported each year — it’s that virtually no such cases are being reported. And for one very good reason: death certificates do not have a category for human or systemic error. In other words, statistically speaking, medical error simply does not exist.

The failure to admit medical error is driven by something else too — fear of lawsuits. Martin Makary, MD, professor of surgery at Johns Hopkins and lead author of the report on error, says fear of the law drives discussion of error underground into “locker rooms, doctor’s lounges, and nursing stations … where they live in the form of stories and not in epidemiological numbers … We have created this wall of silence where we don’t talk openly and honestly about the problems … and that’s why we haven’t even begun to recognize the third leading cause of death in the United States.” (My emphasis)

To better appreciate just how, in Makary’s words, “vastly underappreciated and not even recognized” medical error is, imagine, for example, that every time there was an airline crash we refused to discuss it or, worse, we simply pretended there was none. That’s basically where we’re at with medical error today. The way out, Makarey says, is to address error the way the airline industry addresses pilot error:

“We don’t have a standardized system like aviation. When a plane crashes there’s an investigation. And the entire pilot community worldwide learns something from the crash. But yet in health care the same mistakes happen again and again, and many of them are never investigated … We need solid legal protections for a reporting system … that allows clinicians, coroners, and ME’s, to say this [medical error] was the true cause of death … [to] allow us to finally measure the problem.” (My emphasis)

The “solid legal protections” Makary is asking for already exist in a rule of evidence called “subsequent remedial measures.” It says that when measures are taken that would have made an earlier harm less likely to occur, evidence of the subsequent measures is not admissible to prove fault in a civil lawsuit.

For example, suppose the National Transportation Safety Board investigates an airline crash and determines that a faulty rudder mechanism is responsible. It then submits a report to the Federal Aviation Authority saying so. In turn, the FAA issues a directive to airline companies mandating a change in all aircraft with that kind of rudder. In response, the airlines comply.

Applying the remedial measures rule to this case would mean that in a lawsuit brought against the airline company whose plane crashed, the following could not be used as evidence to prove fault: the fact that there was a NTSB investigation; the NTSB investigative report; the FAA directive based on the report; the subsequent remedial measures taken by the airlines in response to the directive, i.e. replacing the faulty rudder with a safe one.

The reason for the rule is grounded in public safety: in balancing the need to remedy a problem that can affect us all, against the need of a plaintiff in a lawsuit to have all relevant evidence at his disposal, the courts have long since decided that the need for public safety is more important.

That’s what Makary is asking for with respect to medical error: to be able to openly investigate it, truthfully document error when they find it, especially on the death certificate, and to have these things off limits to the courts.

Reducing medical error benefits everyone

Reducing medical error benefits everyone

The reason to truthfully document — to measure — medical error, Makary emphasizes, is because you need good data. Imagine, for example, if there were no category for deaths caused by cancer. If that were so then no government policy, research efforts, or dollars, would flow to combat it. That’s what we have with medical error: since it seemingly doesn’t exist (outside of the domain of lawsuits) the government has no reason to address the error-driven 250 000-plus deaths a year by way of policy, research, or the allocation of funds.

But to begin to honestly measure this error, doctors and hospitals need the “solid legal protections” that Makary is asking for. These legal protections would be local, not federal, and so each state or province would want to draft their own.

This has already been done in many jurisdictions with what’s called the “law of apology.” When a doctor or nurse makes a mistake they can admit it to the patient and their family, and apologize for it, without those statements being used against them in a subsequent lawsuit. Again, we have the threat of suit preventing people from doing the right thing. Yet, nicely, it was the law itself that was used to remove that threat. (Another reason for the rule is that it significantly reduces the number of suits to begin with.)

Notice one more thing: These rules of exclusion (of documents recording error and doctor’s statements) are based on the rules of evidence. They are not based on “tort reform,” a politically charged, divisive topic that seldom leads to anything productive. Rules of evidence, on the other hand, almost by definition invite rational discussion and, more importantly, can be narrowly tailored to fit the facts at hand.

Law and medicine share a bedrock principle: they are both evidence-based professions. That implies a shared way of thinking, and a shared way of practicing law and of practicing medicine. Makary’s plea necessitates that these two like-minded professions finally unite to tackle a problem that doesn’t have to exist, at least to the extraordinary degree that it seemingly does.

The following audio is Dr. Makary’s interview with the British Medical Journal, from which the above quotes have been taken. It’s a rare insider’s account of medicine gone wrong from someone at the top of his profession:

Medical error is the third leading cause of death in the United States — but it’s not something that health care workers feel free to discuss

If medical error was a disease it would rank as the third leading cause of death in the United States, concludes a study just published in the British Medical Journal.

The report pegs the number of deaths at 251 000 a year, a full 100 000 deaths ahead of respiratory illness, which is next in line. Moreover, as high as this number is, it probably underestimates the scope of the problem: “That’s using some of the most conservative numbers in the literature,” says lead author Martin Makary, MD, MPH, and professor of surgery at Johns Hopkins University School of Medicine in Baltimore.

Others agree. Jim Rickert, MD, who was not involved in the study, is an orthopedist in Bedford, Indiana, and president of the Society for Patient Centered Orthopedics. He told Medscape Medical News he was not surprised medical error came in at number 3 and that even those calculations don’t tell the whole story. For example, he notes that the 251 000 figure “doesn’t even include doctors’ offices and ambulatory care centers.” “That’s only inpatient hospitalization resulting in errors,” he says.

And then there’s this: Medical error causing patient death is apparently medicine’s dirty little secret. In an interview with the BMJ, Dr. Makary says: “These are issues that have lived in locker rooms and doctor’s offices and nursing stations where people talk about [these] stories. And it’s almost as if everyone knows of examples they’ve witnessed or know of. But they live in the form of stories and not in epidemiological numbers.”

Notice something else, too: the 251,000 figure refers to medical error causing death. Medical error also causes patient harm that falls short of death. For example: a needlessly prolonged illness, multiple hospital readmissions, the need for surgery, placement in the ICU, further physical and emotional suffering, and so on.

The following chart is taken from the study:




Makary defines medical error in the traditional sense, for instance: a misdiagnosis, a medication mistake, bad judgment, inadequate skill, poorly coordinated care, or a communication breakdown. But he notes that these traditional categories are expanding to include, for example, preventable factors and events, i.e. acts of omission, such as the failure to treat.

So in this emerging category of acts of omission causing harm, consider this fairly typical example of failure to treat in the context of infectious illness. Do you think it constitutes medical error today, and if not, should it?

Imagine, then, you’re in charge of a patient who you know to be colonized with the “superbug” methicillin-resistant staphylococcus aureus (MRSA). Your patient’s name is Sue, a 40-year old single mother of three, aged 7, 10, and 12. She’s been successfully treated for a pneumonia and is about to be discharged. She’s not infected by the MRSA but you’re aware of an important study reported in Clinical Infectious Diseases that says there’s a 1 in 4 chance that she could become infected. And you know that infection leads to the type of harm described two paragraphs above, i.e. multiple hospital readmissions, the need for surgery, etc., which, aside from her own suffering, would jeopardize her income and thus her ability to care for her children. Further, you’re aware of another study that says there’s even a 1 in 7 chance your patient will die if, in fact, she were to become infected with MRSA. So you’re faced with a question: Do you “decolonize” her? That is, do you get rid of the MRSA residing on her skin or in her nostrils, where it’s typically found, thereby removing the foreseeable risk of infection and consequent harm?

The obvious answer would be to decolonize. However, and surprisingly, that is actually not done in most jurisdictions. And here’s the thing: should Sue become MRSA-infected and get sick, or perhaps die, your decision not to treat would not (yet) be considered medical error — at least by health care providers — because non-treatment is the standard of care throughout the land: i.e. that’s how most providers handle a case like this. (But whether a court of law would see it as medical error — as medical negligence — is quite another matter: If your mechanic knew that your car had somewhat faulty brakes and failed to fix them, or failed to even tell you about them, and you crashed as a result, you would have an actionable claim against your mechanic.)

Makary says that “most people underestimate the risk of error when they seek medical care,” calling it a problem that is “vastly underappreciated and not even recognized.” Sue’s case may very well fall within the scope of these statements. If so, her plight is yet further proof of the “vastly underappreciated” nature of this problem.

Ultimately, though, how much harm we can attribute to medical error is unknown, and to some degree probably unknowable. Nevertheless, “the same mistakes happen again and again,” says Dr. Makary, in his interview with the BMJ; and, what’s more, “they’re never investigated.” Which leads us to what he considers the most surprising thing about medical error, what he calls the “Wall of Silence”: the fact that “We haven’t even begun to recognize the third leading cause of death in the United States.”

Makary is right, of course: We haven’t publicly recognized it. But inside those locker’s rooms, doctor’s offices, and nursing stations that he mentions above, are a host of dedicated people who, my guess would be, want to give voice to the issue, both within their ranks, and publicly. But they operate inside what’s been called an “environment of fear.” And so the question becomes: What will it take to change that culture to permit a much-needed open and honest exchange about an issue that in one way or another affects each one of us?

What do you think?











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