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Monday, January 9, 2017

This article will appear in the February issue of EMN.

​BY RUTH SORELLE, MPH 

A New York emergency physician who has lectured and written extensively on evidence-based medicine and the doctor-patient relationship admitted in a New York court on Dec. 16 to five counts of sexually assaulting four female patients in the emergency department at Mount Sinai Hospital.

A source close to the proceedings said on background that 45-year-old David Newman, MD, pled guilty to all counts of the indictment against him, and was promised by Judge Michael Obus of the Supreme Court a sentence of two years in prison and three years of post-release supervision. Prosecutors had sought four years in prison with 10 years of post-release supervision. Dr. Newman was scheduled for sentencing on Jan. 23, and remained free on $50,000 bond at press time. Neither he nor his attorney returned calls from Emergency Medicine News about the case.

Dr. Newman was suspended immediately after the allegations came to light, said a spokesperson for Mount Sinai and is no longer employed at the hospital, where he had been the director of clinical emergency research. "We believe that with this guilty plea today, justice is served," said the spokesperson. "Mount Sinai took prompt and effective steps to aid in this investigation, fully cooperating with authorities to ensure swift action."

In a civil action filed against him, the hospital, and other emergency department personnel, the woman claimed that she was drugged when she sought treatment for shoulder pain at the Mount Sinai ED Jan. 11, 2016. After triage, according to the suit, she received Toradol and Flexeril. A physician and a physician assistant assessed her condition, and the physician introduced her to Dr. Newman, who became her treating physician, the suit said. While she was waiting for an x-ray, she thought the physician gave her morphine through an IV, she said in the suit. (Dr. Newman said it was propofol.)

As she awaited the test results in an exam room, Dr. Newman entered the room and began to fondle her breasts, according to the civil suit. She said in the suit that he told her she needed more pain medication and despite the fact that she demurred and tried to pull her hand away, he gave her another shot of what she believed was morphine. "The effects of the drugs rendered [her] legally incapable of consenting to sexual conduct," the suit said. "While [she] laid on the examination table, [she] heard sounds and saw movement that led her to believe — a belief that was later confirmed by the lab results — that [Dr. Newman] was masturbating. [Dr. Newman] touched [her] breasts and [she] felt an object on her face and mouth. Soon thereafter, [he] ejaculated on [her] face and breasts," according to the suit.

Records indicated that nurses entered the room afterwards and appeared alarmed by her condition, the suit noted. The patient said in the court filing that she asked that Dr. Newman not enter the room again, and told the physician assistant what had happened. He asked if she wanted the police called, and when she said she did and asked to speak to his supervisor, he said Dr. Newman was his supervisor. He advised her to go home and sleep on it before calling the police, according to the suit.

While the plaintiff asked again to be discharged, Dr. Newman suggested she stay. The effects of the drugs resulted in her being too dizzy to leave the hospital and she stayed in the treatment room for about four hours, the suit noted. Eventually, although still feeling the effects of the drugs, she left the hospital and walked home. Once there, she contacted the police, who took her to Harlem Hospital for examination. Swabs taken from her face tested positive for semen, and the DNA was eventually found to match Dr. Newman's, the suit noted.

​Medical Discipline
More than a year will have passed before Dr. Newman faces sentencing for his actions and the actions themselves. Yet in many cases, physicians who sexually abuse patients face no medical discipline at all, according to a report in PLOS One. (Feb. 3, 2016; http://bit.ly/2hCrjSI.) The study by the Public Citizen Health Research Groups spanned nearly a decade (2003 to 2013) and found that 1,039 physicians had one or more report related to sexual misconduct. Most of the malpractice reports involved women or girls and said the misconduct caused "emotional injury," according to the National Practitioner Data Bank. Most had only licensure reports.

Physicians who had been reported for sexual misconduct were more likely to receive serious licensure actions and revocation of clinical privileges than those reported for other activities, but 70 percent were not disciplined by medical boards at all, according to the research report.

The study's lead author, Azza AbuDagga, PhD, called the findings of the report disturbing, despite the limitations of the National Practitioner Data Bank. "[That] more than two-thirds of the physicians with sexual-misconducted-related clinical privileges and malpractice-payment reports were not disciplined by any state medical board for such conduct is concerning because the NPDB" (National Practitioner Data Bank) gives medical boards access to such reports from each of the states, the report said. Dr. AbuDagga noted that the rate of reporting for such abuse is lower than would be expected. Patients often do not report such incidents, she said. Often there is no physical evidence and attorneys are reluctant to take cases when financial rewards are not expected to be huge.

While medical boards are charged with protecting the public from such physicians, there is often no legislative oversight. Dr. AbuDagga said states should look at a law passed in Illinois in 2011 that permanently and immediately revokes the license of a person convicted of a sex crime. "Within a few months [of that law's passage], the state revoked the licenses of 12 professionals who had been convicted of sexual crimes," she said.

"At the end of day, it is all with reporting," said Dr. AbuDagga. "The authorities need to take sexual misconduct and give it the weight it deserves. The damage to these patients is for life."

Preventing such actions starts with the patient, she said. "Patients should ask for a chaperone, especially if they are seeking care that involves an intimate exam," Dr. AbuDagga explained, adding that hospitals should be required by law to query the data bank for every physician they hire or to whom they give clinical privileges. A continuous query that notifies them automatically when a report is sent to the data bank would be the safest, she said.

Patients do not have access to the National Practitioner Data Bank, she said, but they can look up their physician's record through the Federation of State Medical Boards' website. (https://www.fsmb.org/.)

A recent report from the Atlanta-Journal Constitution found that more than 2,400 doctors in the United States have been sanctioned for sexually abusing patients, but the state medical boards allowed more than half of them to keep their licenses. (Dr. Newman's license was suspended soon after the allegations were made, and Mount Sinai forbade him from practicing in the hospital.)

Dr. Newman referred in his book, Hippocrates' Shadow, to a 2005 perspective piece in The New England Journal of Medicine about the lack of professional standards for patient modesty and discretion in the physical examination of patients. "For instance, should there be same-sex chaperones present for examinations of a potentially private body area? And which areas — the waistline, the groin, the buttocks? ... There's no policy, no approved or disseminated guidelines, no ethical writ and no accepted convention."


Wednesday, December 14, 2016

(Last verse only; you're welcome.)

 

BY SCOTT GOLDSTEIN, DO

On the twelfth day of Christmas, the ER sent to me:

12 drunks drinking,

Eleven addicts withdrawing,

Ten ankles-a-limping,

Nine bellies aching,

Eight backs-a-hurting,

Seven trichs-a-swimming

Six geezers-a-laying,

Five kidney stones.

Four calling codes,

Three head bleeds,

Two aortas rupturing,

and a VIP in bed 3.


​Dr. Goldstein is a clinical associate professor of emergency medicine, the director of EMS/disaster medicine, and the director of tactical medicine at Einstein Healthcare Network in Philadelphia. Read his blog, Visual Diagnosis in the ED, at http://visdxed.blogspot.com/, and follow him on Twitter @erdocsg.


Wednesday, December 14, 2016

(Sing to the tune of Adam Sandler's "Chanukah Song.")

BY SCOTT GOLDSTEIN, DO

Put on your PPE,

It's time for Traumakah

So much funukah

To be covered in bloodikah.

 

Traumakah is the festival of fights.

Instead of one day of violence, we have eight crazy nights.

 

When you feel like the only doc in town without a specialty phone tree,

Here are some things we ED docs deal with every day,

just like you and me.

 

New trauma attendings use REBOA,

So do their residents.

Vascular surgeons on the late gunshots that come through the doorah.

Guess who does compressions near the belly.

First-year interns and ED techs when ready.

 

Staples close

half the woundish,

Steri-Strips the other

half, too.

Put them together, what a fine lookin' crew!

 

You don't need "Deck the Halls" or "Jingle Bell Rock"

'Cause you can

access the IJ with US

or a finder needle;

both acceptable.

 

Put on your PPE,

It's time for Traumakah!

 

The owner of

your hospital probably

celebrates Chanukah.

Hemostatics are not a tissue.

 

But guess what is?

Combat gauze and tourniquets.

We got gauze pads and 4x4,

just for dabbing.

Gelfoam and Dermabond aren't too shabby.

Some people think that

being the emergency room is a biz.

 

Well, it's not, but guess what is!

All your bill is.

So many fees are hidden on there.

Meds to help you snooze might not be, but I heard the pain agent is.

 

Tell your friendly COO,

It's time to celebrate Traumakah.

I hope I get a sphygmomanometer.

Oh, this lovely, lovely Traumakah.

So drink your coffee and Red Bull

And take your caffeine pillsakah.

 

If you really, really wannakah,

Have a happy, happy, happy, happy Traumakah.

 

​Dr. Goldstein is a clinical associate professor of emergency medicine, the director of EMS/disaster medicine, and the director of tactical medicine at Einstein Healthcare Network in Philadelphia. Read his blog, Visual Diagnosis in the ED, at http://visdxed.blogspot.com/and follow him on Twitter @erdocsg.


Sunday, October 23, 2016

Dr. Walker interviews Alexis LaPietra, DO, about her Alternatives to Opiates (ALTO) program in his December 2016 and January 2017 columns, where these protocols appear. They are published here to include the references that went into creating them.

ALTO Clinical Applications

Renal Colic
1. Toradol 30 mg IV
2. Cardiac lidocaine 1.5 mg/kg IV in 100 mL NS over 10 minutes (MAX 200 mg)
    a. Patient should be on a cardiac monitor.
3. Acetaminophen 975 mg PO
4. 1 L NS bolus

Musculoskeletal Pain (sprains, strains, or opiate naïve lower back pain)
1. Acetaminophen 975 mg PO
2. Motrin 600 mg PO or Toradol 30 mg IV/IM
3. Muscle relaxant (choose one of the following)
    a. Flexeril 5 mg PO (patients >65 years old or <70 kg or concerns for somnolence)
    b. Flexeril 10 mg PO (patients >70 kg)
    c. Valium 5 mg PO
4. Lidoderm patch to most painful area, MAX 3 patches. Instruct patient to remove after 12 hours.
5. Gabapentin (neuropathic component of pain)
    a. 300 mg PO (patients >65 years old or <70 kg or concerns for somnolence/naïve to med)
    b. 600 mg PO (patients >70 kg or not naïve to med)
6. Trigger point injection with 1-2 mL of Marcaine 0.5% or  Lidocaine 1%

Acute on Chronic Radicular LBP (opiate tolerant)
1. Acetaminophen 975 mg PO
2. Motrin 600 mg PO or Toradol 30 mg IV/IM
3. Muscle relaxant (choose one of the following)
    a. Flexeril 5 mg PO (patients >65 years old or <70 kg or concerns for somnolence)
    b. Flexeril 10 mg PO (patients >70 kg)
    c. Valium 5 mg PO
4. Gabapentin (neuropathic component of pain)
    a. 300 mg PO
5. Dexamethasone 8 mg IV
6. Lidoderm patch to most painful area, MAX 3 patches. Instruct patient to remove after 12 hours.
7. Trigger point injection with Marcaine 0.5% or lidocaine 1% 1-2 mL
8. Ketamine 0.3 mg/kg over 10 minutes 
    a. Ketamine 0.1 mg/kg/hour 

Headache
1. Reglan 10 mg PO/IV
2. 1 L 0.9% NS bolus
3. Motrin 600 mg PO or Toradol 30 mg IM/IV
4. Tylenol 1000 mg PO
5. Cervical or trapezius trigger point injection with Marcaine 0.5% or lidocaine 1%
If <50% pain relief then:
6. Magnesium 1 gm IV over 60 minutes
7. Valproic acid 500 mg/50 cc NS over 20 min
8. Dexamethasone 4-8 mg IV
If <50% pain relief then:
9. Haldol 5 mg IV

Extremity Fracture or Joint Dislocation
1. Ketamine intranasal 0.5 mg/kg (concentration 50 mg/mL)
    a. MAX dose 50 mg; MAX volume per nare 1 mL
2. Nitrous oxide titrate up to 70%
3. Tylenol 975 mg PO
4. Ultrasound-guided regional anesthesia (Print a picture with a new machine and scan into chart)
    a. Joint dislocation
        i. Lidocaine 0.5 % peri-neural infiltration (MAX 5 mg/kg)
    b. Extremity fracture
        i. Ropivacaine 0.5% peri-neural infiltration (MAX 3 mg/kg)

Used with permission. Copyright ©2015 St. Joseph’s Healthcare System. All Rights Reserved.

References
1. Balakrishnamoorthy R, Horgan I, Perez S, Steele MC, Keijzers GB. Does a single dose of intravenous dexamethasone reduce Symptoms in Emergency department patients with low Back pain and RAdiculopathy (SEBRA)? A double-blind randomised controlled trial. Emerg Med J 2015;32(7):525.
2. Blaivas M, Adhikari S, Lander L. A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department. Acad Emerg Med 2011;18(9):922.
3. Colman I, Friedman BW, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008;336(7657):1359.
4. Cleveland Clinic Algorithm: http://bit.ly/MigraineOpioid​.
5. Friedman BW, Dym AA, Davitt M, Holden L, Solorzano C, Esses D, Bijur PE, Gallagher EJ. Naproxen with cyclobenzaprine, oxycodone/acetaminophen, or placebo for treating acute low back pain: a randomized clinical trial. JAMA 2015;314(15):1572.
6. Fahmida Ghaderibarmi, Nader Tavakkoli, Mansoureh Togha. Intravenous valproate versus subcutaneous sumatriptan in acute migraine attack. Acta Medica Iranica 2015;53(10):633.
7. Ferrini R, Paice JA. How to initiate and monitor infusional lidocaine for severe and/or neuropathic pain. J Support Oncol 2004;2(1):90.
8. Galer BS, Gammaitoni AR, Oleka N, Jensen MP, Argoff CE. Use of the lidocaine patch 5% in reducing intensity of various pain qualities reported by patients with low-back pain. Curr Med Res Opin 2004;20(Suppl 2):S5.
9. Gelfand AA, Goadsby PJ. A neurologist’s guide to acute migraine therapy in the emergency room. The Neurohospitalist 2012;2(2):51.
10. Herres J, Chudnofsky CR, Manur R, Damiron K, Deitch K. The use of inhaled nitrous oxide for analgesia in adult ED patients: a pilot study. Am J Emerg Med. 2016;34(2):269.
11. Kranke P, Jokinen J, Pace NL, Schnabel A, Hollmann MW, Hahnenkamp K, Eberhart LH, Poepping DM, Weibel S. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev 2015 Jul 16;7.
12. Linde M, Mulleners WM, Chronicle EP, McCrory DC. Valproate (valproic acid or sodium valproate or a combination of the two) for the prophylaxis of episodicmigraine in adults. Cochrane Database Syst Rev 2013 Jun 24;6.
13. Moore RA, Derry S, Wiffen PJ, Straube S, Aldington DJ. Overview review: Comparative efficacy of oral ibuprofen and paracetamol (acetaminophen) across acute and chronic pain conditions. Eur J Pain 2015;19(9):1213.
14. Cohen V, Motov S, Rockoff B, Smith A, Fromm C, Bosoy D, Hossain R, Likourezos A, Jellinek-Cohen SP, Marshall J. Development of an opioid reduction protocol in an emergency department. Am J Health Syst Pharm 2015;72(23):2080.
15. Soleimanpour H, Hassanzadeh K, Vaezi H, Golzari SE, Esfanjani RM, Soleimanpour M. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urol 2012;12:13.
16. Singh A, Alter HJ, Zaia B. Does the addition of dexamethasone to standard therapy for acute migraine headache decrease the incidence of recurrent headache for patients treated in the emergency department? A meta-analysis and systematic review of the literature. Acad Emerg Med 2008;15(12):1223.
17. Vigneault L, Turgeon AF, Côté D, Lauzier F, Zarychanski R, Moore L, McIntyre LA, Nicole PC, Fergusson DA. Perioperative intravenous lidocaine infusion for postoperative pain control: a meta-analysis of randomized controlled trials. Can J Anaesth 2011;58(1):22.

Wednesday, August 10, 2016

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