At California Hospital, Red Flags and an FBI Raid

REDDING, Calif. — Don Frank, a California lumber salesman with broad shoulders and a modest demeanor, had no reason to question his doctor’s diagnosis of a serious heart problem.

Feeling discomfort in his chest after exercising, Frank decided in the summer of 2002 to see Chae Moon, the chief cardiologist at Redding Medical Center. At 46, married with two sons, Frank was worried about his health. His father — a former patient of Moon’s — had died of heart disease at 51.
Don Frank considered the chain-smoking Moon a personal friend. They were members of the same golf club and often exchanged pleasantries on the course.

Moon gave Frank an angiogram, an ultrasound and some bad news: He said he had spotted plaque in Frank’s left descending artery. “He told me, ‘If that breaks loose, you could be dead before you hit the floor,’ ” Frank recalled.

Frank was shocked but quickly scheduled surgery, taking comfort in Redding Medical Center’s excellent reputation. The 238-bed hospital overlooking the Sacramento River boasted that it did more open-heart surgery and cardiac tests than teaching hospitals twice its size. Just that summer the Joint Commission on the Accreditation of Healthcare Organizations awarded Redding a grade of 94, among the highest in the country.

All of that quickly changed in October 2002, a few months after Frank’s surgery, when FBI agents raided the hospital looking for evidence that doctors were performing unnecessary tests and heart surgery on healthy patients, including Frank.

It took a whistle-blower to alert the FBI about what turned out to be one of the nation’s worst examples of overzealous medicine. But warning signs about Redding were in plain sight for years, documents show. That they were ignored goes a long way toward explaining the breakdown in oversight of the nation’s health providers.

The FBI’s raid spawned waves of allegations that are still playing out. A criminal investigation was opened. Hundreds of civil lawsuits were filed. Redding’s owner, Tenet Healthcare Corp., agreed to pay the federal government $54 million to settle allegations of unnecessary care, without admitting wrongdoing, and to sell the hospital or risk having it barred from Medicare. The hospital is now called Shasta Regional Medical Center.

Still later, Tenet said it would pay $395 million to 769 patients who said they underwent unneeded cardiac procedures at Redding. Moon’s cardiology group also settled with patients, paying $24 million to 345 plaintiffs.

Separately, Moon agreed to a suspension of his medical license. He declined through his lawyer to comment, citing the criminal inquiry.

For years, warning signs at Redding Medical Center were missed by regulators and accrediting organizations. In the mid-1990s, researchers at Dartmouth Medical School reported that Medicare patients in Redding were twice as likely to have open-heart surgery as patients in San Francisco and other California cities. By 2002, the year Frank had surgery, the rate had nearly tripled.

“At the time, we wondered what was going on in Redding,” said John E. Wennberg, the chief Dartmouth researcher.

Curious Parents Family Health Resources

When your child is thirsty, does he or she reach for a soft drink? According to the Academy of General Dentistry, most people will grab a pop, soda or ice tea instead of water, especially during the summer months. It is not just cola’s empty calories with approximately 10 teaspoons of sugar (about 150 per 12-oz can) you should worry about. Many of these beverages, especially non-cola drinks and canned ice tea, harm enamel, the protective shell around the tooth.

A pilot study of the effects some of the beverages had on enamel appeared in a recent journal of General Dentistry. The study suggests that over time, exposing enamel to carbonated beverages and non-carbonated canned ice tea, weakens and permanently destroys enamel.

Healthy dental enamel was exposed to a variety of popular beverages for a period of 14 days. During that time it was discovered that non-colas and ice tea were especially harmful. They contain flavor additives such as malic, tartaric and other organic acids, which are aggressive at eroding teeth. Root beer, which contains the least amount of flavor additives, was found to be the least corrosive to enamel.

Approximately 27 percent of the beverages consumed by Americans are soft drinks. Overall, soft drink consumption has steadily increased over the years and remains on the rise. This contributes to an increase in oral health problems, namely cavities. In 1977, 12 to 19-year-olds drank 16 oz. of soda a day. In 1996, this same age group consumed an average of 28 oz. per day.

All substances that are harmful to your teeth, sugar included, need to have contact with your teeth over time for the destruction to occur. Therefore, you can fight the harmful effects of these beverages two ways. The first and most obvious is to limit the amount of soda and canned ice tea you drink. The less you drink, the less amount of harmful acid comes into contact with your teeth. The second is maybe a less obvious way to help protect your teeth. Limit the amount of time these harmful substances are exposed to your teeth. If you sip soda all day long for example, these substances are in contact with your teeth all day. However, if you were to drink the same amount of soda in one big gulp, the amount of time these substances would actually be in contact with your teeth, is limited to the time of the one big gulp. I am not recommending chugging your soda down, however.

Here are a few guidelines that may help minimize the damage that soda and canned ice tea do to your teeth.

Drinking at one time is better than sipping over a prolonged period of time.

Using a straw may help reduce the amount of soda and ice tea that comes into contact with your teeth.

Rinsing your mouth with water after drinking a soft drink. Drinking at mealtime is less injurious than when consumed alone.

Using toothpaste that contains fluoride.

Estrogen Therapy Does Not Reduce Dementia Risk When Started in Older Women

The most common form of postmenopausal estrogen therapy does not prevent dementia or a decline in memory function when started in women aged 65 and older according to research reported by scientists from the Women’s Health Initiative Memory Study in two articles in this week’s issue of the Journal of the American Medical Association (JAMA).

“Starting estrogen in women 65 years and older to prevent dementia or cognitive decline is not recommended,” said Robert D. Langer, M.D., M.P.H., the principal investigator for the Women’s Health Initiative Memory Study (WHIMS), and a professor of family and preventive medicine at the University of California, San Diego (UCSD) School of Medicine.

The study was designed to test whether the most common forms of estrogen alone, or estrogen plus progestin, lowered the risk of dementia or memory impairment in older women.

Last spring, the researchers reported the first results from the study – that conjugated equine estrogen plus medroxyprogesterone acetate (Prempro™) doubled the risk of dementia in older women and did not benefit global cognition (memory and other basic mental abilities like concentration, language and abstract reasoning). When that study was published researchers weren’t sure if the results would also apply to estrogen alone (Premarin™ in this study), which is given to women whose uterus has been removed.

Now, in JAMA, the researchers report on the group of women who took conjugated equine estrogen alone.

“We found a similar, but weaker, trend toward increased risk of dementia among the women taking estrogen alone,” said Langer. “For every 10,000 women aged 65 or older started on estrogen alone there would be 12 extra cases of dementia per year. In 10,000 women aged 65 or older started on the combined hormone therapy tested there would be an additional 23 cases of dementia per year. Hormone therapy initiated at older ages does not prevent dementia – as was thought when we began this research.”

The researchers also found that global cognition did not improve in women taking hormone therapy. In fact it was adversely affected.

“This adverse effect was relatively small overall, but was more pronounced for women who started with relatively lower cognitive function,” said Mark Espeland, Ph.D., Professor of Public Health Sciences at Wake Forest University Baptist Medical Center and a WHIMS Co-investigator.

WHIMS involved about 7,500 women between the ages of 65 and 79 who were free of dementia when the study started in 1995. Dementia occurs when memory, judgment and other thinking abilities decline substantially, to the point that it interferes with basic day-to-day activities. Alzheimer’s disease was the most common form of dementia found among WHIMS participants.

The study also measured noticeable, but less severe declines in cognitive function, which affect 20 percent to 30 percent of older adults and, for some, strongly predict dementia and future institutionalization. Neither form of hormone therapy prevented the declines.

WHIMS was conducted at 39 centers across the United States. For the estrogen-alone study, about 3,000 women were assigned to take either a daily tablet of conjugated equine estrogen, sold as Premarinä, or an inactive placebo or “dummy” pill. Another 4,500 women took either a daily combination tablet with conjugated equine estrogen plus medroxyprogesterone acetate, sold as Prempro™, or a placebo.

WHIMS is part of the larger Women’s Health Initiative (WHI), designed to study the effects of hormone therapy as well as the long-term effects of a high-fiber, low-fat diet on heart disease and how vitamin D and calcium affect bone density and fracture rates. These two trials of WHI will continue through 2005.

In July 2002, women in WHI and WHIMS were told to stop taking the estrogen plus progestin therapy because the risks for developing breast cancer, strokes and cardiovascular disease outweighed the benefits. In March 2004, women in the estrogen-alone study were told to stop taking their drugs due to an increased risk of stroke, along with no difference for heart disease or breast cancer. Both groups of women are still being followed to determine the long-term effects of hormone therapy.

WHIMS was funded by Wyeth Pharmaceuticals and Wake Forest University Baptist Medical Center. The WHI is funded by the National Institutes of Health.

Nursing shortage drums up demand for happy nomads

Amy Morrison has turned the USA’s nursing shortage to her advantage.

		Amy Morrison checks a patient at Tarzana Regional Medical Center in California.
		By Robert Hanashiro, USA TODAY

The 32-year-old nurse hung up her Ohio scrubs six years ago and hit the road. She’s one of an estimated 20,000 U.S. “traveling nurses” who move from hospital to hospital on assignments typically lasting 13 weeks. Travel nurses help hospitals fill workforce gaps and, in some cases, keep hospital units open.

Morrison’s traveled for six years, working in such places as Hawaii, Alaska, New York and California. She’s made 25% more than if she’d stayed in Ohio, she estimates, and the former farm girl has seen the country on someone else’s dime. “It’s a great life,” she says.

The travel-nurse industry, which suffered with the economy in recent years as staff nurses sought overtime and hospitals balked at travel-nurse costs, is on the rebound. Thousands of jobs are open, staffing companies say. Demand for travel nurses at No. 1 AMN Healthcare Services is up 50% since the start of the year, CEO Susan Nowakowski says. Rival Cross Country Healthcare says its orders are at 30-month highs. And recruitment is so competitive that one company, Access Nurses, is launching a travel-nurse reality show, 13 Weeks, at www.nursetv.com.

This fall, six nurses placed in Southern California hospitals will soak up the lifestyle in a beachside mansion supplied by Access and have their work and play videotaped for seven-minute webcasts. “Our objective is to let young people know travel nursing is a viable career, and you can have an exciting lifestyle,” says Access CEO Alan Braynin. “We have nurses who ski in winters and surf in summers.”

The travel-nurse concept largely originated to serve “snowbirds” moving from northern to southern states in winters. Several trends point to long-term growth, says Barry Asin, with research firm Staffing Industry Analysts. Baby boomers are aging, requiring more health care. Schools aren’t graduating nurses fast enough. California recently mandated a 1-to-5 nurse-patient ratio for the bulk of hospital beds, up from 1-to-6. More states, including Florida, are considering ratios to improve patient care. The U.S. government expects the national nurse shortage to hit 800,000 by 2020.

California, where the nursing shortage is especially acute, has 14,000 open nursing jobs. “In many cases, hospitals plug those jobs with travelers,” says Jan Emerson, spokeswoman for the California Hospital Association.

Nationwide, travelers staff about 1% of nursing jobs, says Joseph Boshart, CEO of Cross Country.

But staffing companies say the largest market is California, which has fewer nurses per capita than every state except Nevada.

Community Medical Centers in Fresno, which includes four Central California hospitals, has about 6% of its 1,200 nursing jobs staffed with travelers. At the Natividad Medical Center in Salinas, travel nurses account for 15% of its 250-nurse staff.

There are signs of increasing demand elsewhere. Lawmakers in New Jersey recently introduced legislation requiring health care facilities to notify the state if 40% of its nursing or nursing aid positions are filled by temporary workers.

Pluses and minuses

Hospitals say they have mixed feelings about the travel-nurse industry. The nurses fill in when staff nurses take leaves of absence. And they provide continuity for weeks at a time compared with per-diem nurses who are usually hired on a day-to-day basis to staff positions.

Yet travel nurses typically cost hospitals at least 20% more than a nurse employee, even when benefits are factored in, says Carol Bradley, chief nursing officer for California for Tenet Health System, with 18 California hospitals.

While travel nurses may be highly skilled, they may also be less familiar with a hospital’s procedures and doctors, says Deborah Burger, president of the California Nurses Association. “Travelers might not be as familiar with equipment, the hospital layout, who to call. … Minutes can make a huge difference,” she says.

Some doctors have complained. The New Mexico Department of Health, during a February inspection of the Albuquerque Regional Medical Center, interviewed 17 doctors who said they were “extremely concerned” about the “lack of permanent well-trained nursing staff,” the state’s report said. It noted that the intensive care unit had 12 of 25 positions filled by travel nurses on one day of the inspection. The hospital’s CEO told the state that the hospital had difficulty attracting nurses to hire.

Wide pay range

While Staffing Industry Analysts estimates 15,000 to 20,000 travelers work in U.S. hospitals daily, industry executives estimate there are twice that many who have traveled before and may again.

Travel nurses are usually employed by staffing companies. Salaries vary by experience, location and specialty, but generally run $22 to $35 an hour. That means a nurse working 40-hour weeks 50 weeks a year would make $44,000 to $70,000. A travel nurse in California may push $100,000 a year, with overtime, Access CEO Braynin says.

Most staffing companies also offer medical and 401(k) benefits. They typically pay travel costs and provide housing and food stipends for nurses while they’re on the job. The nurses tend to be younger or empty nesters with a yearning for travel and better pay, says Ralph Friedmann, CEO of staffing firm InteliStaf Healthcare.

Sometimes, travel nurses don’t travel far. Jennifer Nies, 25, is working as a travel nurse in Pomona, Calif. She lives 50 miles away in Burbank — far enough away to be considered a travel job but close enough to commute three days a week. Through her employer, Comforce Staffing Services, she says she makes almost twice what she would if employed as a staff nurse.

Hospitals are doing more to recruit and keep staff nurses. Morrison says she’s always asked to stay on. Natividad has nurse mentoring and housing loan programs. Bradley says Tenet in California uses the travel-nurse program to try to recruit permanent nurses. California also is trying to expand nursing education through a $90 million initiative announced in April. Some of the state’s nursing programs have wait lists that run three years.

For now, though, travel nurses largely call the shots. Scott Smiley, 40, a 10-year nurse, spent the last three as a traveler for World Health Alternatives. His home is in Soso, Miss., but he’s worked in Wisconsin, South Dakota, Louisiana and California. When he got to his current assignment in McComb, Miss., World Health put him up in a hotel. He asked to be moved to a cabin at a nearby state park. He was.

Smiley works seven days and then travels home for seven days. His wife works locally as a nurse, and they have two daughters, ages 15 and 6.

“I travel, make twice as much and work half the time,” he says.

Preventing Holiday Hand Injuries

Preventing Holiday Hand Injuries

It happens every year at the holidays: The UCSD Medical Center Emergency Room pages the surgeon on call for the UCSD Hand Surgery Service to examine a hand injured by an errant knife while carving a turkey, cutting open pumpkins or other hard squash, or chopping all the food ingredients that goes into holiday meals.

But, says Reid Abrams, M.D., Chief of the Hand Surgery Service, a little caution and a few common sense rules can prevent a painful injury, surgery, and lengthy treatment.

Abrams offers up the following tips for a safe and pain-free holiday season:

* Always cut away from yourself. And, when cutting into a pumpkin or turkey, don’t place your free hand opposite the side where the blade is entering. If you push too hard you will impale your hand.
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* Carve and chop in a well-lit, dry area so you can see what you’re doing and the item you’re carving won’t slip.

* Make sure the handles of your chopping and carving instruments are dry when using them, so your cutting hand doesn’t slip down the handle and onto the blade accidentally slicing your hand.

* Consider using an electric knife for ease of carving turkey or a ham.

* A good pair of kitchen sheers eases the job of cutting bones and joints.

* Keep your meat carving and chopping knives very sharp. Nothing causes accidents faster than a knife too dull to cut but sharp enough to slice into your hand. Be careful not to force the knife. If your knife is sharp you won’t have to force it.

* Children should not be allowed to carve meat or pumpkins. They don’t yet have the dexterity or coordination to work with sharp instruments.

* Finally, if you do get hurt while carving, if it’s a deep wound or if you can’t control the bleeding, get to an emergency room as soon as possible.

Court sides with California nurses

California nurses have won the first round against Gov. Arnold Schwarzenegger in a very public fight over a law that sets minimum nurse staffing levels in the state’s hospitals.

		Liz Diewock, a Santa Monica nurse, demonstrates in Sacramento.
		By Rich Pedroncelli, AP

A state Superior Court judge sided with the California Nurses Association Friday in ruling that the governor overstepped his authority in issuing an emergency order that delayed by three years a further reduction in the number of nurses to patients on the state’s medical/surgical wards.

“This is probably the single biggest setback for this governor since he’s been in office,” says Chuck Idelson, a spokesman for the nurses union.

The fight is likely to continue. Both the hospital industry and the state vow to appeal the court decision.

“We don’t have a problem with the ratios conceptually if we had the workforce to meet them,” says Jan Emerson, spokeswoman for the California Hospital Association, who says 4,000 additional nurses would be needed statewide if the judge’s ruling is not overturned.

In the meantime, the nurses continue a barrage of criticism and street theater: In the weeks before the ruling, the nurses duked it out with the governor in a series of public protests, including hiring airplanes to trail anti-Schwarzenegger banners at the Oscars and taking out advertisements criticizing the governor as too tied to big business.

Today, they’re expected to protest the governor as he attends a political fundraiser in Washington.

Trouble started in November when the governor issued the emergency order delaying by three years a reduction in nurse ratios from one-nurse-to-six-patients to one-to-five, saying there are not enough nurses to hire to meet those ratios.

Schwarzenegger further angered nurses in December when a group of them interrupted his remarks at a women’s conference, and he called them “special interests” who “don’t like me in Sacramento because I kick their butt.”

The ratio reduction was to have gone into effect in January, a year after the initial law mandating ratios began.

His order left intact existing ratios of one nurse to six patients on medical wards, one to four in pediatric wards and one to two in intensive care.

The nurse staffing law was passed by California lawmakers who cited research showing that patients get better care when more nurses are on duty. It is the first state to mandate staffing levels throughout hospitals, although other states set ratios in intensive care units.

The nurses union says the ratios will improve patient care and nurses’ satisfaction with their jobs.

“Gov. Schwarzenegger fought the law — and the patients won,” says Rose Ann DeMoro, executive director of the union, in a written statement.

But the hospital industry has questioned whether the staffing levels will improve care and say many facilities are already struggling to hire enough nurses despite California having some of the highest nursing salaries in the nation, with new nurses making $60,000 a year or more.

Emerson, at the hospital association, says the nurses union has its eye on a bigger prize: expanding membership beyond California to nurses in other states.

“If they’re going to follow the governor all over the country, that’s not caring about patients in California,” she says.

A Survival Guide For A Safe Holiday Season

University of California, San Diego Medical Center and the California Poison Control System offer these seasonal tips to help keep the season safe.

“The holidays are traditionally a time when family and friends get together to celebrate,” said Carlos Rojas, M.D., Associate Clinical Professor of Family Medicine, at University of California, San Diego, Medical Center.

Alcohol poisoning is common in children throughout the year, but increases during the holidays. This often occurs when children drink the leftover cocktails after parties, or when adults allow them to drink from their glasses, said Rojas. Adults should make sure alcoholic drinks are cleaned up and out of reach during and after a party.

Also, colognes, perfumes and after-shave contain heavy concentrations of alcohol. Small children might ingest these products by mistake if they are attractively packaged. Children are very sensitive to alcohol, especially to its ability to lower blood sugar, said Rojas.

Toy-related injuries peak during the holidays. Parents should carefully review the toys on their child’s wish-list and consider the responsibility level of the child. Small toys which break easily may be swallowed by small children and pets and cause serious injuries. Potentially dangerous items such as darts, slingshots and BB guns can cause injury and loss of sight, especially during the excitement of holidays, said Rojas.

Additionally, small batteries — used in watches, cameras and calculators — can be quite dangerous if swallowed. They may cause burns or leak chemicals that cause poisoning.
Hidden Holiday Hazards

“Plants and products usually not seen or available during the first 10 months of the year account for many problems during the holiday season,” said Lee Cantrell, Pharm.D., interim director of the California Poison Control System, San Diego Division, at University of California, San Diego Medical Center. This may pose a problem for curious pets and young children especially.

“When visiting friends and relatives, especially those without small children, make sure their home is poison-proof,” said Cantrell.

For example, most people don’t know that all parts of mistletoe are toxic, and the berries may cause poisoning in children, explained Cantrell.

In addition to mistletoe the leaves, and especially the berries, of English holly are toxic. Ingestion of 20 or 30 berries can cause very serious poisoning.

Some seasonal nontoxic plants include pyracantha, eugenia and California holly. Poinsettias are essentially nontoxic, but can cause stomach upset if ingested, and the milky sap can cause some skin irritation. Also, Christmas cactus and pine cones are nontoxic.

Christmas tree needles such as pines, spruces and junipers may cause stomach upset if large amounts are ingested. Ingestion of small amounts may cause a localized irritation of the mouth.

Some Christmas decorations may be dangerous. Care should be taken to hang glass bulbs and light bulbs high on the tree to prevent accidents. Angel hair, or spun glass, is very irritating to the skin and eyes. Ornaments imported from other countries may be painted with a lead paint and could be toxic if ingested. Tinsel manufactured prior to 1972 also contains lead; however, the major problem with ingestion of large amounts of tinsel is obstruction of the gastrointestinal tract, said Cantrell.

Medicine, cosmetics and other small items from grandma’s purse or grandpa’s coat pocket can frequently be swallowed by small children. Make sure that visitors to your home store packages and purses out of a child’s reach, said Cantrell.
Food Tips

Southern California is known for having warm holiday weather, so even though summer is over, certain precautions should be taken to fight food poisoning.

At warm temperatures — 60 degrees and over — food poisoning bacteria can begin to multiply and cause illness. While food poisoning usually means uncomfortable intestinal flu-like symptoms, it can be serious — in the young, the elderly, and people with other illnesses.

Keep everything that touches food clean. Wash hands before preparing food. Cook food thoroughly and if your holiday meal is left out and reaches room temperature, it could become a source of food poisoning. By observing the cold storage, sanitation and thorough cooking rules you can keep your food safe during the holidays.

If an ingestion of a questionable product occurs or you have questions about the potential toxicity of anything in your home, call the California Poison Control System, San Diego Division, at UCSD Medical Center, toll free at (800) 876-4766. The Poison Control System offers a 24-hour-a-day information service on the toxicology, clinical signs and symptoms, assessment and treatment of exposures to toxic substances.